Policies and Procedures for Graduate Medical Education 2017-2018

Policies and Procedures for Graduate Medical Education 1

Table of Contents INTRODUCTION 5

I. INSTITUTIONAL ORGANIZATION AND RESPONSIBLITIES 5 I.A. Sponsoring Institution 5 I.B. Participating Sites 6 I.C. Statement of Commitment to Graduate Medical Education (GME) 6 I.D. Accreditation for Patient Care for Hospitals 6

II. INSTITUTIONAL RESOURCES 7 II.A. Institutional Resources 7 II.B. Program Administration 7 II.B.1. Program Director 7 II.B.2. Faculty 7 II.B.3. Other Administrative Staff 8 II.C. House Staff Forum 8 II.D. Educational Tools 9 II.E. Support Services and Systems 9

III. HOUSE STAFF LEARNING AND WORKING ENVIRONMENT 9 III.A. How to Raise and Resolve Issues 9 III.B. UK Commitment to House Staff Engagement 13 III.B.1. Patient Safety Reporting System 13 III.B.2. Access to Data for Quality Improvement 13 III.B.3. Transitions of Care 13 III.B.4. House Staff Supervision 13 III.B.5. Fatigue Management 13 III.B.6. Professionalism 13

IV. INSTITUTIONAL GME POLICIES AND PROCEDURES 13 IV.A. House Staff Recruitment, Eligibility, and Selection Policy 13 IV.B. House Staff Transfers Policy 15 IV.C. Program or Institutional Closure and Reduction Policy 15 IV.D. House Staff Appointments and Reappointments Policy 16 IV.E. Discrimination and Harassment Policy 17 IV.F. Disability and Accommodations Policy 17 IV.G. Grievance Procedures and Due Process 18 IV.H. Off-Site Rotations Policy 18 IV.I International Rotations Policy 19 IV.J. Vendor Relations Policy 20 IV.K. Extreme Emergent Situation or Disaster 20 IV.L. Breastfeeding Policy 20

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V. HOUSE STAFF BENEFITS

21

V.A. Professional Liability Insurance 21 V.B. House Staff Health Insurance Benefits 21 V.C. Long Term Disability Program 22 V.C.1 Short Term Disability 22 V.D. Workers Compensation 22 V.E. Leaves of Absence 22 V.E.1 Family Medical Leave (FML) 22 V.E.2 Temporary Disability (Sick) Leave 23 V.E.3 Vacation, Holiday and Bonus Leave 23 V.E.4 Funeral Leave 24 V.E.5 Educational Leave 24 V.E.6 Military Leave 24 V.F. UK House Stipend Scale 24 V.G. Funding Sources and Pay Systems 24 V.H. Health Benefits 25 V.I. Licensure 25 V.J. DEA 25 V.K. On-Call Quarters 25 V.L. Parking Permits 26 V.M. Uniforms 26 V.N. E-Mail 26

VI. HOUSE STAFF RESPONSIBILITIES, DISCIPLINARY ACTION, AND GRIEVANCE PROCEDURES 27 VI.A. House Staff Responsibilities 27 VI.B. Remediation and Discipline Policy 29 VI.B.1. Preliminary Academic Action/Notice of Concern 29 VI.B.2. Formal Disciplinary Actions 30 VI.B.2.a). Non-promotion of a House Officer 30 VI.B.2.b). Probation 31 VI.B.2.c). Suspension 31 VI.B.2.d). Non-Renewal of Appointment 32 VI.B.2.e). Dismissal/Termination 32 VI.C. Clearance 33

VII. HOUSE STAFF WELL BEING 33 VII.A. Self Care

33 VII.B. Coverage of Patient Care 34 VII.C. Counseling and Mental Health Resources 34

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VII.D. Impairment Policy 34

VII.E. Voluntary Self-Referral for Drug/Alcohol Counseling in the Absence of Performance Issues

35

VII.E.1. Impaired Physicians Program 35 VII.E.2. Required Evaluation for Mental Health or Drug/Alcohol Concerns by Others in the Context of Performance Related Concerns Policy

36

VII.F. Return to Duty 36 VII.G. Refusal to Cooperate 37

VIII. PROGRAM EDUCATIONAL CURRICULUM 37 VIII.A. Curriculum 37

VIII.B. House Staff Scholarly Activities

39 VIII.C. Other Learners Policy 39 VIII.D. Experimentation and Innovation 39

IX. EVALUATION 40 IX.A. House Staff Evaluation/ Clinical Competency Committee 40

IX.A.1. Formative Assessment 40 IX.A.2. Semiannual Evaluation 41 IX.A.3. End-of-Program Summative Evaluation Policy 42 IX.B. Faculty Evaluation Policy 42 IX.C. Program Evaluation and Improvement Policy 43

X. THE LEARNING AND WORKING ENVIRONMENT 44 X.A. Transitions of Care 45

X.B. Alertness Management / Fatigue Mitigation 45 X.C. Supervision of House Staff Policy 45 X.D. Clinical Responsibilities 46 X.E. Teamwork 46 X.F. Clinical and Educational Assignments 46 X.F.1. Maximum Hours of Work per Week 47 X.F.2. Mandatory Time Free of Work 47 X.F.3. Maximum Length of Work Assignments 47 X.F.4. Minimum Time Off between Scheduled Work Periods 48 X.F.5. Maximum Frequency of In-House Night Float 48 X.F.6. Maximum In-House On-Call Frequency 48 X.F.7. At-Home Call 48 X.F.8. Clinical and Educational Work When Traveling 49 X.G. Moonlighting Policy 49 X.H. Program Oversight for House Staff Work Hours Policy 49 X.H.1. Reporting Duty Hours Violations 50

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X.I. Institutional Oversight for House Staff Work Hours Policy 50 XI. INSTITUTIONAL OVERSIGHT 51

XI.A. Graduate Medical Education Committee Functions and Responsibilities 51 XI.B. Graduate Medical Education Committee Membership 53

XI.C. Compliance Subcommittee 53 XI.D. Educational Development Subcommittee 54 XI.E. Program Review Subcommittee 55 XI.C. House Staff Complement Increase / Funding Requests 57 XI.D. New House Staff Training Program Request 57 XI.E. Non-ACGME Accredited Training Programs 58 XI.F. Policy Modification 59

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Policies and Procedures for Graduate Medical Education

INTRODUCTION This manual contains general standards, policies and procedures that govern all programs in graduate medical education (GME) at the University of Kentucky (UK). The term, “GME,” as used in this document encompasses residency and fellowship programs accredited by the Accreditation Council on Graduate Medical Education (ACGME), programs in dentistry, oral and maxillofacial surgery, optometry, medical physics, pastoral care, pharmacy and health administration. In addition to the standards outlined in this policies and procedures document, individual programs have additional program specific standards, policies and procedures created and maintained by the individual programs. The term, “house officer (singular)/ house staff (plural)” as used in this document includes interns, residents, and fellows. GME is also governed by relevant sections of the University Administrative Regulations (AR), relevant sections of the University Human Resource Policy and Procedure, the Health Care Colleges Code of Student Professional Conduct, University Student Rights and Responsibilities, Behavioral Standards in Patient Care, Commitments to Performance, and the University of Kentucky/UK HealthCare Behavioral Expectations for Service Excellence: Commitments to Performance.

I. INSTITUTIONAL ORGANIZATION AND RESPONSIBILITIES

I.A. Sponsoring Institution There are six healthcare colleges within the University of Kentucky HealthCare Enterprise including the colleges of Medicine, Dentistry, Pharmacy, Nursing, Health Sciences, and Public Health. The various health care colleges serve as the sponsoring institution for their associated GME program. Authority and control over all GME programs accredited at the University of Kentucky is managed through the GME Office. In addition, the UK Healthcare Enterprise includes the UK Albert B. Chandler Hospital, the UK Good Samaritan Hospital, Kentucky Clinics, Kentucky Children’s Hospital, the Center for Excellence in Rural Health (in Hazard, KY), and several multidisciplinary centers of excellence.

GME is supported by the respective Dean of the College, the Executive Vice President for Health Affairs (EVPHA) for the UK HealthCare Enterprise, the Provost and the President of the University of Kentucky. The Deans of the Healthcare Colleges report both to the EVPHA for clinical activities and to the Provost for academic activities. This is accomplished through the Healthcare Colleges Committee. The Associate Dean for Graduate Medical Education, who also serves as the Designated Institutional Official (DIO) (these two terms are used interchangeably throughout this document), reports to the Dean of the College of Medicine through the Senior Associate Dean for Medical Education. The DIO in collaboration with the Graduate Medical Education Committee (GMEC), has authority and responsibility for the oversight and administration of the Sponsoring Institution’s accredited GME programs, as well as responsibility for ensuring compliance with the ACGME Institutional, Common, and specialty/subspecialty-specific Program Requirements, the ACGME Policies and Procedures, and all other accrediting body standards through continuous oversight mechanisms.

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The Associate Dean is an ex officio member of the organized medical staff committee. Program Directors bear responsibility not only to the department chairperson, but also to the GMEC, the DIO and the ACGME Review Committee (RC).

I.B. Participating Sites A participating site is a location other than the sponsoring institution at which residents receive a portion of their education. Oversight of all educational assignments and of the quality of the learning and working environment for GME extends to all participating sites. House staff must only be assigned to learning and working environments that facilitate patient safety and health care quality. There must be a program letter of agreement (PLA) between the program and each participating site providing an assignment. The PLA should identify the faculty who will assume both educational and supervisory responsibilities for residents; specify their responsibilities for teaching, supervision, and formal evaluation of residents; outline the goals and objectives for the rotation; specify the duration and content of the educational experience; and state the policies and procedures that will govern resident education during the assignment. The PLA must be renewed at least every five years or be addended with any substantial leadership changes (such as a change in Program Director or site director). The program director must submit any additions or deletions of participating sites routinely providing an educational experience, required for all house staff, of one month full time equivalent (FTE) or more through the ACGME Accreditation Data System (ADS) after approval by the DIO.

I.C. Statement of Commitment to Graduate Medical Education (GME) The University of Kentucky provides graduate medical education that facilitates resident professional, ethical, and personal development. The University of Kentucky and its programs support safe and appropriate patient care through curricula, evaluation, and house staff supervision. A written statement of commitment to provide the necessary educational, financial, and human resources to support GME is reviewed, dated, and signed by representatives of the governing body, senior administration and GME leadership including the UK Healthcare Enterprise, the Dean of the College of Medicine and the Designated Institutional Official (DIO) of GME at least once every five years or upon substantial changes in leadership (see Appendix).

I.D. Accreditation for Patient Care for Hospitals The UK Chandler Hospital, UK Good Samaritan Hospital, and/or major participating sites are appropriately accredited by the Joint Commission, by another entity with reasonably equivalent standards as determined by the ACGME Institutional Review Committee (IRC), by another entity granted “deeming authority” for participation in Medicare under federal regulations, certified as complying with the conditions of participation in Medicare set forth in federal regulations, or recognized by another entity with reasonably equivalent standards as determined by the IRC. In the event a hospital loses its accreditation, the Sponsoring Institution must notify and provide a plan of response to the Institutional Review Committee (IRC) within 30 days of such loss. Based on the particular circumstances, the IRC may request the ACGME to invoke its “egregious or catastrophic” policy.

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II. INSTITUTIONAL RESOURCES II.A. The University of Kentucky provides sufficient institutional resources to ensure the effective implementation and support of its programs in compliance with the Institutional, Common, and specialty/subspecialty specific program or other accreditation requirements. The University of Kentucky provides sufficient financial support and protected time to the DIO to effectively carry out his/her educational, administrative and leadership responsibilities to the sponsoring institution. The DIO assumes responsibility for and is supported to engage in professional development applicable to the responsibilities of an educational leader. The University of Kentucky and the programs ensure sufficient salary support and resources (e.g., time, space, technology, supplies) to allow for effective administration of the GME Office and all of its programs.

II.B. Program Administration

II.B.1. Program Director For every program there is a single program director with authority and accountability for the operation of the program. The Program Director meets the qualifications as outlined in the specialty/subspecialty program requirements or as been otherwise approved by the applicable accrediting body. The program director should continue in his or her position for a length of time adequate to maintain continuity of leadership and program stability. Requests for change in program director must be submitted to the Compliance Subcommittee for review via the following link: http://gme.med.uky.edu/new-program-director-request-form. Such requests must include appropriate documentation of qualifications that are in compliance with the requirements as outlined by the applicable RC. The Compliance Subcommittee, after review of the documentation and program requirements submits a recommendation to the GMEC. The GMEC must approve a change in program director. After approval, the DIO will submit the change to the ACGME via Web ADS. Each program director bears responsibility for the organization and implementation of the program n o t only to the department chairperson, but also to the GMEC, the DIO, and the associated ACGME review committee. The program director must administer and maintain an educational environment conducive to educating the house staff in each of the ACGME competency areas. Specific tasks may be delegated, but the program director is responsible for the program as a whole and for the timely and accurate completion of all required tasks. A complete list of program director duties are outlined in the document Responsibilities of the Residency and Fellowship Program Director (see Appendix). II.B.2. Faculty The program must ensure that for each educational assignment, there must be a sufficient number of faculty with documented qualifications to instruct and supervise all house staff at that location. The faculty must: • Devote sufficient time to the educational program to fulfill their supervisory and

teaching responsibilities; • Demonstrate a strong interest in the education of house staff; • Administer and maintain an educational environment conducive to educating house

staff in each of the ACGME competency areas;

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• Establish and maintain an environment of inquiry and scholarship with an active research component;

• Regularly participate in organized clinical discussions, rounds, journal clubs, and conferences; and,

• Encourage and support house staff in scholarly activities. The physician faculty must have current board certification in the specialty/subspecialty or possess qualifications acceptable to the Review Committee. The physician faculty must possess current medical licensure and appropriate medical staff appointment. The non-physician faculty must have appropriate qualifications in their field and hold appropriate institutional appointments. II.B.3. Other Administrative Staff The University of Kentucky and the program jointly ensure the availability of all necessary professional, technical, and clerical personnel for the effective administration of the program including a designated Program Coordinator(s) who, in conjunction with the Program Director is held accountable to the GME Office for all sponsoring institution and program accreditation requirements. The University of Kentucky in collaboration with each accredited program, also ensures the following: the program director has sufficient financial support and protected time to effectively carry out their educational, administrative, and leadership responsibilities as described in the Institutional, Common, and specialty/subspecialty-specific Program Requirements or other accreditation standards as delineated in the Program Director Protected Time and Support Policy (see Appendix); programs receive adequate support for core faculty members to ensure both effective supervision and quality house staff education; program directors and core faculty members engage in professional development applicable to their responsibilities as educational leaders through sponsoring institution or academic society based development opportunities; program coordinators have sufficient support and time to effectively carry out their responsibilities; and, resources, including space, technology, and supplies, are available to provide effective support for all accredited programs.

II.C. House Staff Forum The University of Kentucky ensures the availability of a House Staff Council (see Appendix) that allows house staff from across the Sponsoring Institution’s accredited programs to communicate and exchange information with each other relevant to their accredited programs and their learning and working environment. Any house officer from one of the Sponsoring Institution’s accredited programs has the opportunity to raise a concern directly to the forum or through their peer selected representative. House staff have the option at the end of the formal monthly meeting, to conduct their forum without the DIO, faculty members, or other administrators present. Concerns raised during this time are brought to either the Associate or Assistant Dean for GME by a member of the House Staff Council Executive Committee who also serve on the GMEC.

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II.D. Educational Tools The University of Kentucky is committed to providing faculty and house staff ready access to adequate communication resources and technological support. House staff have ready access to specialty/subspecialty-specific and other appropriate reference material in print or electronic format in individual program libraries and/or the Medical Center Library at http://www.uky.edu/Libraries/lib.php?lib_id=12 Electronic medical literature databases with search capabilities are available on the library web site or the UK Healthcare Care Web site at http://www.hosp.uky.edu/careweb/carehome.asp?PageName=General&Section......

II.E. Support Services and Systems The University of Kentucky, in conjunction with the other members of the UK Healthcare Enterprise, is committed to providing services in a health care delivery system that minimizes house staff work that is extraneous to their GME programs’ educational goals and objectives, and to ensure that house staff educational experience is not compromised by excessive reliance on house staff to fulfill non-physician service obligations. Support services and systems that are provided include patient support services, laboratory, pathology, radiology and medical records to support house staff education, high quality and safe patient care, quality improvement and scholarly activities. Provisions are made for a healthy and safe work environment with 24-hour food services, call/nap rooms, and appropriate security.

III. HOUSE STAFF LEARNING AND WORKING ENVIRONMENT III.A. How to Raise and Resolve Issues The University of Kentucky is committed to having a positive learning and working environment for its house staff. All individuals have the right to enjoy an environment free from all forms of conduct that can be considered abusive, harassing, threatening or intimidating. Every individual must be allowed to raise concerns or express opinions in a non-threatening atmosphere of mutual respect and in a confidential manner as appropriate. The University of Kentucky is committed to providing options for house staff to raise and resolve concerns involving patient safety, programs, attending/staff, personal or other issues without intimidation or fear of retaliation. The University of Kentucky, under the Associate Dean for GME will adjudicate those house staff complaints and grievances related to the work environment, the program, or the faculty.

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Departmental RiskManager

Each program is required to provide its house staff with guidelines on how to raise and resolve issues. Most concerns should be dealt with at an individual program level in consultation with the chief resident/fellow, program director, faculty or chairperson. In the event that those efforts do not bring resolution to the concerns or if a house officer is not comfortable bringing forth issues within their own program then the following alternative support systems can be used as depicted above.

GME Office The GME Office, including the Associate or Assistant Dean, has an open door policy. Any member of the house staff with a concern may request assistance at any time. The house officer can also raise a

ImpairedPhysicians

GME DeanGME Office

Chief Residents Chair

Program Director

Attending/FacultyMember

Chief Residents

Attending/ FacultyMember

GME DeanGME Office

GME DeanGME Office

House Staff Academic Ombudspersons

Impaired PhysiciansProgram

Mechanisms to Raise and Resolve Issues

PersonalIssue

Program Related Issue

Patient Safety

Issue

Resident has a

About or For another Resident

UK HumanResources Attending/Faculty

Member Service Chief

Chair Program Director Chief Residents rector

Service Chief

Attending/FacultyMember

Employee Assistance Program (REFER)

Resident Crisis ReferralProgram

Impaired PhysiciansProgram

Chair Program Director

Attending/ FacultyMember

Hospital RiskManagement

Chair Program Director

Chair Program Director

Chief Residents

Chief Medical Officer

Department HR Officer

House Staff Academic Ombudspersons Patient Safety Net

http://careweb.mc.uky.edu/psn/

GME DeanGME Office

House Staff Council

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concern using the MedHub Messaging function to anonymously submit a message to the GME Dean or access the GME website at http://gme.med.uky.edu/ and use the Ideas and Suggestions button.

House Staff Council Peer-selected members of the house staff are chosen annually to serve as representative to the House Staff Council. The goals of the House Staff Council are to work with those involved in GME:

• to promote high quality patient care and educational experiences throughout the various training venues

• to actively participate in quality improvement at training sites • to effectively address issues that affect house staff quality of life and the training environment,

including, but not limited to, call quarters, access to information, meal availability, and resources to reduce non-educational activities.

Any member of the house staff may contact a House Staff Council representative to have concerns brought to the council for review as outlined in the House Staff Council Policy (see Appendix). House staff can submit a concern to House Staff Council via the following link: http://gme.med.uky.edu/submit-concern-house-staff-council. This link is also provided on the main GME website page at http://gme.med.uky.edu/.

House Staff Academic Ombudspersons From among the faculty of the UK College of Medicine, the Assistant or Associate Dean for GME shall appoint, with the advice and consent of the House staff Council, several House Staff Academic Ombudspersons whose role it is to mediate issues of concern raised by the house staff with representatives of the institution. Examples of such issues might include, but are not limited to, irresolvable conflicts between the house officer and the program director or a belief that the house officer is being unfairly treated. It is the task of the Ombudsperson to investigate to the best of his/her ability the house officer’s issues, reach a judgment on the merits of the complaint, and to counsel the house officer as to avenues to explore in resolution. This is to be accomplished, whenever possible, through communication between and among the House Staff Academic Ombudsperson, the program director and other persons whom the House Staff Academic Ombudsperson deems to be useful. In cases where resolution cannot thus be achieved, or in cases where a program is believed by the House Staff Academic Ombudsperson to be substantially in violation of the Institutional Requirements, Program Requirements or other policies of the institution or program, he/she shall prepare a report for the Assistant or Associate Dean describing the problems identified, attempted resolution to date and recommendations of potential avenues of resolution. The Assistant or Associate Dean will then initiate a focused review of the program focused on the issues raised by the report of the House Staff Academic Ombudsperson. House staff consultation with the Ombudsperson should be confidential, except in circumstances in which to keep confidence would, in the opinion of the Ombudsperson, put at risk the health and safety of any individual.

Available House Staff Academic Ombudspersons include:

Dr. Charles (Chipper) H. Griffith at cgrif00@email.uky.edu Dr. Todd R. Cheever at tbchee0@email.uky.edu Dr. Christopher Feddock at cafedd00@email.uky.edu

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Counseling Services Under the auspices of the Department of Psychiatry, access to confidential consultation regarding the need for non-emergent psychiatric services is available through the UK Outpatient Clinic during business hours, five days per week. The telephone number is 859-323-6021. Follow prompts for the Outpatient Clinic.

Resident Crisis Referral Program Under the auspices of the Department of Psychiatry, access to confidential consultation regarding the need for emergency psychiatric services is available to residents 24 hours per day, seven days a week through the admissions office at The Ridge Behavioral System. The telephone number is 859-268-6400. The resident should ask for the Assessment Office and identify him/herself as a UK resident needing immediate evaluation. If admission is required, the caller will be asked to go directly to The Ridge, bypassing evaluation in the UK Emergency Department.

Through the Employee Assistance Program, REFER is a professional therapy clinic (UK Family Center) available to help with personal, couple, or family concerns. REFER is staffed by Marriage and Family Therapists-In-Training, educated with the skills necessary to help work through a variety of personal issues. Contact the UK Family Center at 257-1467 or 257-7755 for additional information.

Impaired Physicians Program The Impaired Physicians Program (IPP) of the Kentucky Physicians Health Foundation (or equivalent for other specialties) will provide assistance to physicians with mental health or drug/alcohol related illness. It provides evaluation, referral for treatment and ongoing aftercare including regular meetings and compliance monitoring. IPP never reports participating physicians to the Kentucky Board of Medical Licensure unless 1) the physician is an imminent danger to the public, 2) the physician refuses to cooperate with IPP, or 3) the physician does not follow the treatment plan and/or does not respond to treatment. IPP serves as an advocate for the recovering physician with the Kentucky Board of Medical Licensure and other appropriate agencies. Help for oneself or a peer can be obtained confidentially by calling 502-425-7761.

Human Resources Human Resources at the University of Kentucky can be contacted at (859) 257-9555 or through the website at http://www.uky.edu/HR/.

Risk Management Risk Management for UK Chandler Hospital, Kentucky Children’s Hospital, and Good Samaritan can be contacted at (859) 257-6212.

Patient Safety To report a patient safety incident on-line go to .http://careweb.mc.uky.edu/psn/.

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Some concerns raised potentially have injurious and far-reaching effects on the careers and lives of accused individuals. Therefore, allegations must be made in good faith and not out of malice. Knowingly making a false or frivolous allegation will not be tolerated.

Every effort will be made to prevent retaliation directed at a person who has filed a complaint or participated in an investigation of an allegation. Any person found to have engaged in or attempted any form of retaliation is subjected to disciplinary action per University of Kentucky policy.

III.B. The University of Kentucky is committed to house staff engagement in and oversight of:

III.B.1. Patient safety, including access to systems for reporting errors, adverse events, unsafe

conditions, and near misses in a protected manner that is free from reprisal; and opportunities to contribute to root cause analysis or other similar risk-reduction processes.

III.B.2. Quality improvement, including access to data to improve systems of care, reduce health

care disparities, and improve patient outcomes; and opportunities to participate in quality improvement initiatives.

III.B.3. Transitions of care, including facilitating professional development for Program Directors, core

faculty members and house staff regarding effective transitions of care; and ensuring a standardized transitions of care consistent with the setting and type of patient care.

III.B.4. Supervision of house staff that is consistent with institutional and program-specific policies and

mechanisms by which house staff can report inadequate supervision in a protected manner that is free from reprisal.

III.B.5. Clinical and educational assignments, fatigue management, and use of mitigation strategies

consistent with the Common and specialty/subspecialty-specific Program Requirements; addressing areas of non- compliance in a timely manner; promoting systems of care and learning in working environments that facilitate fatigue management and mitigation for house staff; and educational programs for house staff and faculty members in fatigue management and mitigation.

III.B.6. Professionalism through provision of systems for education in and monitoring of house staff

and core faculty members’ fulfillment of educational and professional responsibilities, including scholarly pursuits; accurate completion of required documentation by house staff. Programs must provide a professional, respectful, and civil environment that is free from mistreatment, abuse, or coercion of students, residents, faculty, and staff.

IV. INSTITUTIONAL GME POLICIES AND PROCEDURES IV.A. House Staff Recruitment, Eligibility, and Selection Policy Recruitment and selection of house staff is the responsibility of the programs. Each program must have a policy with standards, appropriate to the specialty, to guide house staff selection. The recruitment

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and selection processes, including the solicitation for applicants, screening of applications, invitation for interview, interview, applicant evaluation and ranking must be conducted in an ethical manner.

The program must inform all applicants who are invited for an interview, in writing or by electronic means, of the terms, conditions, and benefits of their potential appointment, including financial support; vacations; parental, sick, and other leaves of absence; professional liability, hospitalization, health, disability and other insurance provided for the house staff and their families; and the conditions under which the Sponsoring Institution provides call rooms, meals, laundry services, or their equivalents. The program director must have all interviewed applicants sign the Interviewee Acknowledgement Form indicating this information has been received as well as the GME Authorization and Release of Application Information form, both available on the GME web site at http://gme.med.uky.edu/prospective-residents-fellows.

Applicants are eligible for appointment if they are graduates of schools approved by the Liaison Committee on Medical Education (LCME ) or the American Osteopathic Association (AOA) or, in the case of international schools, approved for listing by the World Health Organization or equivalent accrediting bodies and possess a valid Educational Commission for Foreign Medical Graduates (ECGMG) certificate or have a full and unrestricted license to practice medicine in a US licensing jurisdiction in which they are training. Graduates of medical schools outside the US who have completed a Fifth Pathway program provided by an LCME-accredited medical school are also eligible for appointment. Dental residents must hold a DDS or DMD degree from a school approved by the Commission on Dental Accreditation (CODA) or if graduates of foreign dental schools, must satisfy state licensure requirements for a limited permit to practice dentistry.

Selection from eligible applicants must be based on training program-related criteria such as applicant preparedness, ability, aptitude, academic credentials, communication skills, and personal qualities such as motivation and integrity. Programs must not discriminate with regard to sex, race, age, religion, color, national origin, disability, or any other applicable legally protected status. All medical trainees must meet the minimum selection criteria as described by the ACGME, American Board of Specialties (ABMS) or AOA for the specialty.

House staff who require visas are sponsored on J-1 visas through the ECFMG. House staff are sponsored on H-1B visas only in rare cases. These require justification from the applicant and program director, and approval from the Provost’s office. Visa issues or questions should be referred to the GME office.

All programs offering positions must participate in the National Resident Matching Program, or program-specific equivalent (if available), and abide by its ethical and procedural rules. Positions unfilled in the match may be offered to qualified applicants by program directors, but such offers must be made with a clear communication to the applicant, both verbally and in writing, that appointment is contingent on the applicant meeting program and institutional requirements and passing a credential review by the program, the GME Office and the DIO. A template offer letter is available via contacting the GME office.

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The program director may not appoint more house staff than approved by the applicable Review Committee unless otherwise stated in the specialty-specific requirements and approved by the GMEC through a complement increase request. The sponsoring institution and programs educational resources must be adequate to support the number of house staff appointed to the program. Appointment is effected through execution of a contract between the applicant and the sponsoring institution which is processed by the GME office and signed by the DIO or designee.

IV.B. House Staff Transfers Policy The GME Office must be notified prior to initiating the acceptance of a transferring house staff member. The transferring house staff member must sign a GME Authorization and Release of Applicant Information form before information is exchanged between institutions/programs.

Before accepting a house staff member who has prior graduate medical education training, the program director must obtain written or electronic verification of previous educational experiences and a summative competency-based performance evaluation of the transferring house staff member including an assessment of competence in the following areas:

1. Patient Care including procedural data 2. Medical Knowledge 3. Practice-Based Learning and Improvement 4. Interpersonal and Communication Skills 5. Professionalism 6. Systems-Based Practice

The GMEC also recommends that program directors of programs with training prerequisites whose entry level is at the PGY-2 level or higher also make personal contact with the program director or other individuals able to evaluate the resident’s performance.

UK program directors are required to provide timely verification of education and summative performance evaluations for house staff in likewise fashion to other requesting programs for any house staff who may leave the program prior to completion of their education.

IV.C. Program or Institutional Closure and Reduction Policy Economic or other conditions may force the closures of a sponsoring institution, a program or a reduction in the size of a program. The University of Kentucky, through the DIO should give as much notice as possible to the Graduate Medical Education Committee and all affected residents in the event of any anticipated changes.

In the event that the University of Kentucky or program is closed, the program must allow residents already in the program to complete their education or assist the residents in enrolling in an ACGME, ASHP or CODA accredited program in which they can continue their education. In the event that alterations are made to program size, only the number of future positions to be offered will be changed. Residents who have been appointed in a program are not at risk for losing their positions; all residents will be allowed to complete their programs.

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IV.D. House Staff Appointments and Reappointments Policy All house staff new to the University of Kentucky are given a conditional offer of appointment. The offer is contingent upon the successful completion of a background check and drug screen, as well as upon primary source verification of credentials to confirm that the individual possesses the basic requisite education, training, skills, personal characteristics, and professionalism to make the experience as house staff a successful one for the individual and for the program. Failure by house staff to meet all conditions of appointment will result in revocation of the offer of appointment. This action is not appealable through the University. Should the applicant feel that a Match violation has occurred; he/she may contact the National Residency Match Program (NRMP) or other applicable Match program.

The program director may not appoint more house staff than approved by their specialty Review Committee, unless otherwise stated in the specialty-specific requirements and approved by the DIO. The program’s educational resources must be adequate to support the number of house staff appointed to the program.

All written agreements of appointment/contracts are for one year and each house staff member must be reappointed for each subsequent year of training, contingent upon satisfactory completion of the current post-graduate year and assurance that all requirements are met for progression. House staff are provided with appropriate financial support and benefits to ensure that they are able to fulfill the responsibilities of their educational program. Terms and conditions of appointment to a program are outlined in the contract. The sponsoring institution will honor the full term of the contract except when a house staff member’s performance justifies termination.

Recommendations for the appointment and reappointment of house staff are initiated by programs. The appointment and reappointment of house staff is the responsibility of the DIO, based on the recommendation of the program director and is contingent upon review of credentials of the applicant, assurance of GME requirements met when applicable and acceptable progress in the program. No house staff member will be asked to sign a non-competition guarantee or restrictive covenant.

A decision regarding reappointment must be reached by the program director no later than 4 months prior to the end of the current appointment unless the house staff member is on suspension or probation. For most house staff who are on a July 1 – June 30 contract year, this decision must be made prior to March 1.

Appointment and/or reappointment does not constitute an assurance of successful completion of a training program or post-graduate year. Successful completion is based on performance as measured by individual program standards. Reappointment is the usual expectation if the house staff member is making normal progress toward attainment of the learning objectives of the program and board eligibility (if applicable).

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House staff are expected to notify their department sufficiently in advance (preferably by March 1st) if they do not intend to return the following year.

In instances where a house staff member’s contract will not be renewed, or when a house staff member will not be promoted to the next level of training, the program director, after review with and concurrence by the DIO, must provide the house staff member with a written notice of intent no later than four months prior to the end of the house staff member’s current contract. If the primary reason(s) for the non-renewal or non-promotion occurs within the four months prior to the end of the contract or the house staff member is on suspension or probation, the program director must ensure that its provide the house staff member with as much written notice of the intent not to renew or not to promote as circumstances reasonably allow, prior to the end of the contract. Nonrenewal and non- promotion are both grieveable actions. See Disciplinary Procedures as outlined in this manual and AR 5.5; Grievance Procedure for House Officers for additional information.

IV.E. Discrimination and Harassment Policy The University of Kentucky values the contribution of all students including house staff, faculty, staff and visitors in our community. Discrimination and harassment create a harmful atmosphere that denies house staff the right to an education. The University of Kentucky will absolutely not tolerate discrimination or harassment of any student, house officer, faculty, staff or visitor. Information regarding the University of Kentucky policy and procedures for handling allegations of discrimination and harassment can be found at http://www.uky.edu/EVPFA/EEO/pdf/OfficeBrochure.pdf Or Administrative Regulation AR 6:1 at www.uky.edu/Regs/files/ar/ar6- 1.pdfwww.uky.edu/Regs/files/ar/ar6-1.pdf

House staff may contact the GME office or the Office of Institutional Equity and Equal Opportunity at (859) 257-8927 with any questions or concerns. Additional information may be found at this website http://www.uky.edu/EVPFA/EEO/discrimination_faq.htmlhttp://www.uky.edu/EVPFA/EEO/discriminat ion_faq.html IV.F. Disability and Accommodations Policy In accordance with the University of Kentucky Equal Opportunity Employment policy, programs do not discriminate in its admissions or selection of house staff. The University of Kentucky is committed to providing quality educational and occupational opportunities for everyone, including qualified individuals with disabilities. The University is dedicated to providing reasonable accommodation to qualified students, house staff, employees, and all those with disabilities participating in its programs and services.

Applicants to University of Kentucky programs who may need reasonable accommodations at any point in the selection process, as well as incoming or current house staff who may require reasonable accommodations may consult with the GME office or the Office of Institutional Equity and Equal Opportunity or visit the website at:

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http://www.uky.edu/EVPFA/EEO/reasonable_accommodation.html Requests for accommodations are evaluated on a case-by-case basis.

House staff may also contact the Disability Resources Center, for concerns related to academic accommodations including educational testing services at: http://www.uky.edu/StudentAffairs/DisabilityResourceCenter/ IV.G. Grievance Procedures and Due Process It is the intention of the University of Kentucky to deal fairly with house officers. In the normal course of working together on a day-to-day basis, problems in connection with the working relationship can be expected to arise. In most cases, the problem can and should be resolved at the first level of supervision. However, when a mutually satisfactory solution cannot be worked out at the first level, the house officer should be given an opportunity to appeal the decision without fear of prejudice. The Grievance Procedure for House Officers outlines the method of dealing with house officer grievance in a prompt and equitable manner without placing an unreasonable burden on the University’s resources and personnel (see Appendix).

IV.H. Off-Site Rotations Policy Definitions: ACGME Required/Suggested Experience: Reference to the educational activity is listed in the ACGME (or equivalent for non-physician programs) program requirements and indicated as being a required or suggested experience.

With few exceptions, the institution (University Hospital, College of Medicine) does not pay for off-site rotations. The following guidelines are in place: Educational Activity is ACGME Required/Suggested Experience:

• If educational activity is required and available at UK – off-site rotation not permitted* • If educational activity is required and not available at UK – off-site rotation permitted • If educational activity is suggested elective and available at UK – off-site rotation not

permitted* • If educational activity is suggested elective and not available at UK –off-site rotation permitted

with approved justification Educational Activity is Not ACGME Required/Suggested Experience:

• Must count toward required training • Must be funded by the off-site provider or individual program

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All off-site rotations must be approved by the Assistant or Associate Dean and require that a fully executed agreement be in place before the beginning of the rotation. It is the responsibility of the program to initiate a Program Letter of Agreement (PLA) between the University and the site no later than four months before the rotation is to begin. Forms necessary for this purpose are available on the GME website: http://gme.med.uky.edu/gme-resources. In doing this, the PLA:

• Identifies the faculty who assume both the educational and supervisory responsibilities for house staff. If the rotation is to a US facility other than an ACGME accredited training site, the supervisor must be a member of the UK Community-Based Faculty, or have similar credentials at another ACGME accredited training program;

• Specifies the faculty responsibilities for teaching, supervision, and formal evaluation of house staff, as specified later in this document;

• Specifies the duration and content of the educational experience; • States the policies and procedures governing house staff education during the assignment; and • Outlines the goals and objectives for the rotation.

In addition, the program must identify the payment source for the house officer's stipend and benefits while he/she is on rotation, if applicable. If necessary the program must secure agreement of the site to which the house officer is to rotate to pay for stipend and benefits, or identify that costs are to be covered using departmental funds.

Faculty at sites to which house officers rotate must provide training that is consistent with both the general and program specific academic standards that govern GME at UK.

*May request an exception or be funded by off-site provider or program

IV.I. International Rotations Policy

House staff are eligible to request participation in a one-week international rotation experience during their training program. Requests for additional time beyond this one week must be made by the Program Director to the Assistant or Associate Dean with appropriate educational justification. House staff may participate in international rotations under the following conditions:

1) The activity is part of the training program in that it meets an ACGME requirement and is counted toward assuring the graduate’s board eligibility.

2) The activity represents a significant educational opportunity that cannot be achieved at UK. 3) Participation in the activity does not negatively affect the training of other house staff in the

program. 4) Participation in the activity does not negatively affect delivery of care at UK.

Program directors wishing to sponsor a house officer to participate in an international rotation must request permission to do so in writing no less than four months before the proposed activity. If the program RC or board requires approval then permission must be sought well in advance of the intended experience and will require GMEC approval. The request must describe the proposed rotation, name the responsible supervisor and state the competency based learning objectives. It must address explicitly each of the four conditions listed above. The request should be submitted to the

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Assistant or Associate Dean for GME who will have it reviewed for educational effectiveness by the College of Medicine International Committee. See the Policy on International Rotations for complete details (see Appendix).

IV.J. Vendor Relations Policy The UK Healthcare Clinical Code of Conduct Addendum addresses interactions between vendor representatives/corporations and house staff/GME programs (see Appendix). House staff wishing to participate in vendor sponsored educational activities must complete the Alternative Educational Funding request form and receive approval prior to the activity date (see Appendix).

IV.K. Extreme Emergent Situation or Disaster Emergency Delays and Closures The University of Kentucky may be impacted by weather-related opening delays or closures. Such changes will result in "Plan B"/non-essential scheduling changes for the University that may NOT include UK HealthCare. While “Plan B” scheduling occurs relatively infrequently, typically related to severe weather, it is important that all house staff and training programs be aware of responsibilities and processes related to unexpected delays or closures. House staff are required to follow the “essential employees” scheduling and must report to work on a normal schedule even in the event of an announced delay, closure or cancellation. In the event UK Healthcare schedule is different from that of the University, house staff must follow the UK HealthCare schedule. If the clinical responsibility for a house officer is delayed or canceled by UK HealthCare scheduling they must report to their Program Director for alternative scheduling. House staff must follow similar institutional policies when rotating at outside facilities.

For the purposes of this policy, a disaster is an event or set of events causing significant alteration to the house staff experience at one or more sponsoring institutions and/or training programs (such as Hurricane Katrina) while an extreme emergent situation is a local event (such as a hospital-declared disaster for an epidemic) that affects house staff education or the work environment in a single institution.

In the event of a disaster or extreme emergent situation leading to a disruption in patient care, the University of Kentucky will provide assistance for continuation of house staff assignments as possible and continue to provide administrative support for its GME programs as delineated in the Extreme Event Policy for Emergent Situation or Disaster (see Appendix).

IV.L. Breastfeeding Policy House staff who are breastfeeding are protected by Kentucky Revised Statute 1. UKHC and GME are committed to providing resources consistent with the University of Kentucky’s policies which can be found: https://www.uky.edu/hr/work-life/resources-for-parents/uk-lactation-guidelines

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V. HOUSE STAFF BENEFITS V.A. Professional Liability Insurance Professional liability insurance for house staff in the form of occurrence coverage is provided by the University of Kentucky's self-insured professional liability insurance plan for activities that are an approved component of the training program. Risks incurred within UK Healthcare Enterprise, at outside clinics and hospitals as part of an approved rotation are covered under this plan. Risks incurred while practicing at the VA Medical Center are covered by the Federal Tort Claims Act.

Coverage for internal moonlighting is provided. There is no coverage under the University of Kentucky‘s program for external moonlighting.

Occurrence coverage means that regardless of when the claim is filed, as long as the house officer cooperates in the institution's defense of the claim the self-insured plan will pay for all costs associated with defense of the claim, as well as the cost of any settlement or judgment. Even if a house officer is no longer with the University of Kentucky when the claim is filed, as long as he or she was acting within the scope of his or her duties and responsibilities of the University of Kentucky training program then the self-insured plan remains in force. Therefore, it is not necessary for house staff to purchase tail coverage for their duties on behalf of this institution. However, if risks were incurred elsewhere (e.g., during medical school or while moonlighting) where a policy only provided claims-made coverage, then a tail would be necessary to protect those individuals.

The reference number for house staff coverage under the University of Kentucky Malpractice Insurance plan is KRS 164.939. Insuring limits are in excess of $1,000,000 per occurrence and $3,000,000 in the aggregate. Requests for certificates of insurance (documenting malpractice coverage) should be directed to the GME office. Additional questions about the scope of professional liability coverage should be directed to the Department of Risk Management.

V.B. House Staff Health Insurance Benefits House staff, their spouses, approved domestic partners, and dependent minor children are eligible for health, dental, vision, life and accidental death and dismemberment insurance at the University of Kentucky. House staff are eligible to receive University of Kentucky health credit for these benefits under the regular full-time employee category. Insurance coverage for these benefits begins on the date of appointment and last day of their separation month (i.e. June 30th for most house staff). House staff may also participate in health care and dependent care flexible spending accounts. Residents sponsored on a J1 Visa must ensure adequate coverage is purchased for their dependents sponsored on a J2 Visa. Further details are available via consultation with the GME office.

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V.C. Long Term Disability Program The University of Kentucky provides Long Term Disability (LTD) to all house staff at no additional cost. House staff are eligible for LTD plans effective the first day of the month following twelve (12) consecutive months of regular full-time appointment. For additional information concerning benefits under the Long Term Disability Program and/or for options available during the first 12 months of appointment, consult Human Resources Policy and Procedure Number 95.0: http://www.uky.edu/hr/benefits/more-great-benefits/long-term-disability

V.C.1. Short Term Disability Participation in voluntary short-term disability plans is available. Contact the Benefits Office at 859- 257-9519 to obtain information about these options.

V.D. . Workers Compensation The University of Kentucky provides Workers Compensation to all house staff who incur job-related injury or illness. House officers must file a report of injury with UK Workers’ Care by calling 1-800-440- 6285. This must be done no matter where the job-related injury or illness occurred (for example, even when rotating at a participating site, the report of injury is filed with UK Workers’ Care). For additional information concerning benefits under the Workers’ Compensation Act, contact the GME office or consult Human Resources Policy and Procedure Number 96.0 http://www.uky.edu/hr/benefits/more- great-benefits/workers-compensation

V.E. Leaves of Absence Leave requests must be approved through appropriate department channels prior to the leave being taken. When leave is taken for any reason, specialty board requirements supersede university policy. This may require the extension of training beyond the usual number of months. Available leave time including vacation cannot be used to make up required training time unless permitted by the specialty/subspecialty board. Specific board requirements regarding leave may be found at the applicable Board website.

V.E.1 Family Medical Leave (FML) Recognizing the occurrence(s) of serious health conditions which involve either the University employee or a qualified family member, the University provides Family Medical leave of up to 12 weeks in a 12-month period. House staff are strongly encouraged to work closely with your program director and coordinator as appropriate. For additional information concerning benefits under the FML, contact the GME office or consult Human Resources Policy and Procedure Number 88.0

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http://www.uky.edu/HR/policies/hrpp088.htmlhttp://www.uky.edu/hr/policies/family-and-medical- leave

V.E.2 Temporary Disability (Sick) Leave House staff earn one day per month temporary disability (TDL) sick leave. The TDL leave must be earned before it can be used. Unused TDL leave carries over into the next contract year for house staff. Unused TDL leave allowances will not be paid upon completion of the residency/fellowship, termination or resignation. TDL may run concurrently with FML, if applicable. For additional information concerning benefits under the Temporary Disability (Sick) Leave Program, contact the GME office or consult Human Resources Policy and Procedure Number 82.0 http://www.uky.edu/hr/policies/temporary-disability- leave

V.E.3. Vacation, Holiday, and Bonus Leave Vacation and holiday leave are outlined in the house staff contract. House staff at the PGY1 level receive 10 days of vacation for their PGY1 contract year. House staff at the PGY2 and above levels receive 15 days of vacation per year. House staff also receive 8 holidays (9 during a presidential election year), and 4 bonus days each year. Leave days are provided in accordance with University policy. Total leave time provided per academic year must be balanced with specialty board leave requirements. Extensions of training may be required if time off per academic year exceeds specialty board leave requirements. The Program Director is responsible for monitoring leave and specialty board requirements. Insofar as possible, house staff are to be given the 8 defined holidays off. However, patient care demands and educational requirements may necessitate that a house officer work on a holiday. Should that occur, the house officer should be given an in-lieu day and allowed to take the “holiday” on another day. Bonus days normally occur between Christmas and New Year’s Day. Again, patient care demands and educational requirements may require that a house officer work any or all of those days. Should that occur, the house officer is to be given an in-lieu day (or days) and allowed to take the “bonus day (or days)” on another day (or days). Holidays and bonus days are not typically counted when determining allowed time off for board eligibility. Vacations, holidays and bonus days are to be scheduled with the appropriate individual(s) in the program; and are to be approved by that individual(s). In most cases, vacation time should be taken while training with the “home” program. If the house officer is rotating to another program, then the time must be requested of, and approved by, both program directors (rotating program and home program). Vacations, holidays and bonus days are to be taken within the contract year, and will not be carried forward if not used.

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V.E.4. Funeral Leave House staff are eligible for Funeral leave. For additional information concerning benefits under Funeral Leave, contact the GME office or consult Human Resources Policy and Procedure Number 84.0

V.E.5. Educational Leave Programs may allow house staff to take educational leave for attendance at meetings or conferences or courses that further the education of the house officer. V.E.6. Military Leave Per GMEC approval, house staff are eligible for military leave as indicated by the University of Kentucky’s Uniformed Services Leave, Policy # 75.0 which can be found: www.uky.edu/hr/policies/uniformed-services- leave-military-leave House staff requesting leave must submit a written request, along with a copy of the military orders, to GME as well as his/her department as soon as the order is received.

V.F. UK House Staff Stipend Scale Link to most current stipend list: http://gme.med.uky.edu/gme-stipends (stipends are not approved until one month before the academic year begins) Note: Entering PGY level is assigned at the lowest level eligible for training in that specialty or subspecialty regardless of individual trainees prior PGY level or prior number of years in training. House staff are contracted on a year-to-year basis. Though it is the expectation that you will be contracted each year for the duration of your training program; it is your responsibility to assure you meet the requirements of the training program and the institution(s) (UK and those to which you rotate) for that to occur. Please also reference the section on Policies and Procedures Related to Postgraduate Trainees. V.G. Funding Sources and Pay Systems The majority of funding for house staff is provided through the University Hospital, the Veterans Affairs (VA) Medical Center, community hospitals/health care entities and grants. All house officers are paid monthly on the last working day of the month from the GME office. A system for direct deposit of payroll checks is mandatory and available for any commercial bank, savings and loan institution, and/or credit union that is a member of the National Automated Clearing House Association (NACHA). To set up direct deposit, visit the myUK Employee Services site: https://myuk.uky.edu/irj/portal. Because of the proximity and partnership between UK and VA, the majority of house officers will have dual appointments in both hospitals, as appropriate.

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V.H. Health Benefits House Staff are considered Regular, Full-Time Employees. Click link for health benefits rate chart: http://www.uky.edu/hr/benefits/employee-medical-plans/employee-health-plans-rates

V.I. Licensure All PGY2s and above must be licensed by the Kentucky Board of Medical Licensure prior to the start of their training at UK. Any PGY1 who has had prior ACGME or AOA- accredited training must also be licensed before beginning training. Licenses are renewed annually. All renewals must be processed through the GME office in order that the fees may be paid. You will receive notification from both GME and MedHub when your renewal is due. UK sponsors residents for Institutional Practice (IP) licenses, or Residency Training (R) licenses. An IP license is for house staff who have not yet passed USMLE Step 3, or for those who have passed USMLE Step 3 but the program director has indicated to the licensure board that he/she is not allowed to moonlight. An R license is granted to those who have passed USMLE Step 3. Should you wish to obtain a full license (after two years of training), that is something you would complete on your own. The financial responsibility is that of the requesting resident. UK GME pays the Kentucky Board of Medical Licensure (KBML) for renewals of IP and R licenses for residents. Should you be a new resident coming to us who paid yourself for the IP or R license, GME will reimburse you the $75 fee. Please provide either a copy of your cancelled check or a receipt to the GME office. Fellows are sponsored for a full medical license. GME pays the Kentucky Board of Medical Licensure (KBML) for fellows’ license renewals. If you are a new fellow joining UK and paid for the FT or full license, GME will reimburse you for the cost of the license. GME does not reimburse for associated fees. For reimbursement, provide either a copy of your cancelled check or a receipt to the GME office. V.J. DEA You must hold a Kentucky medical or dental license in order to obtain DEA certification. There are two options for DEA licenses, Fee Exempt and Fee Paid. If you intend to externally moonlight, you will need a Fee Paid DEA. The fee is the responsibility of the individual house officer. GME will assist you in processing your DEA.

V.K. On-Call Quarters On the first floor of the Chandler Hospital Pavilion H, there are 35 call rooms. These rooms are assigned to specialties or designated as nap or home-called in, and are available for use when house staff are required to stay in the hospital overnight or need a place to rest due to fatigue. Each room contains a bed, desk, chair, closet, and phone, and shares a bathroom with one other call room. Access to the call room quarters is accomplished by swiping your ID badge. Some departments (e.g., Obstetrics/Gynecology, Pediatrics) maintain their own call rooms. Information about said call rooms

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should be obtained from the relevant department. At Samaritan, call room keys may be obtained from the nursing supervisor and must be returned to the nursing supervisor at the end of the shift. The call rooms have a bed, desk, computer and phone and shares a bathroom. V.L. Parking Permits Parking permits will be issued to each trainee upon completion of the parking application or online renewal. These permits are hang tags that must be displayed from the rear view mirror. Permits are assigned to an individual, not a vehicle. The hang tag cost is covered by the GME office, however house staff are responsible for any fines or replacements. House Staff should park only in areas designated employee lots and not park on yellow lines, service areas or the emergency room area. Illegally parked vehicles will be towed. Should you receive a parking citation and feel that an appeal is in order, you may appeal on-line at www.uky.edu/Parking V.M. Uniforms The GME office provides funding for 3 lab coats / year. Programs may approve residents to receive scrubs sets (non-surgical) in lieu of lab coats during the annual uniform ordering process. You will receive your first order during orientation into your new program. Each additional year, you will be prompted to complete an online order for your uniform needs. Surgical scrubs are available in designated areas of the hospital via the scrub vending systems. Contact the GME office to request access to the scrub machines (if your badge won’t allow you to gain access). All surgical scrubs must be returned to the machine prior to completion / clearance from your training program.

V.N. E-Mail All house officers will be issued a UK Exchange/Outlook e-mail address for the duration of their postgraduate training. This e-mail account should be utilized for all UK business. Personal e- mail accounts will not be used by UK faculty and staff to communicate with you. Your UK e-mail should be checked on a regular basis, as it is a primary method of written communication.

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VI. HOUSE STAFF RESPONSIBILITES, DISCIPLINARY ACTION, AND GRIEVANCE PROCEDURES VI.A. House Staff Responsibilities House staff are expected to conduct themselves in a professional manner regarding achievement of educational objectives, provision of patient care and relations with their colleagues. The appointment contract makes explicit these expectations and makes reference to other relevant documents that govern resident behavior. They are the University Administrative Regulations (AR), the Chandler Medical Center Behavioral Standards in Patient Care, the Behavioral Code and other Medical Center documents, all of which are available via the GME Office. House staff must be informed of these general academic standards at orientation and provided ready access to the relevant documents through the GME Office and/or the program. Should a resident be excused from orientation because of illness, or for any other reason, it is the GME Office's responsibility to assure that the house officer is informed of these general academic requirements.

House Staff must:

• Devote time and interests fully to the welfare of the patients assigned; • Provide compassionate, efficient and cost-effective care commensurate with level of training

and responsibility; • Assume responsibility in the teaching or professional direction of students and other

interns/residents/fellows; • Be responsive to the supervision and direction of professional staff involved in educational and

patient care activities; • Take advantage of all opportunities offered to improve my knowledge and skills in the

profession; and • For additional information see Professionalism, Personal Responsibility, and Patient Safety as

outlined below.

House staff are also bound to and must abide by Behavioral Standards, and agree to abide by the policies, regulations and procedures of any hospital or institution to which they are assigned for any part of training and other responsibilities as assigned by the program. Any misrepresentations or failures to fully disclose requested information shall be sufficient cause to result in the immediate revocation of appointment or denial of appointment. House staff contract may be terminated for any serious or repeated breach of ethics or discipline. All house staff are required to apply for a Kentucky license at the earliest date for which he/she is eligible. House staff are responsible to for the completion of all examination and licensure requirements. Fellows must apply for a full Kentucky license which requires successful completion of USMLE Step 3. Fellows cannot be appointed without successful completion of USMLE Step 3 and a full Kentucky license prior to the appointment date. Appointment and/or stipend and benefits as a PGY-2 or above (PGY-1 for pharmacists and dentists) will be contingent upon having a valid state of Kentucky license. Any incoming medical resident at a PGY1 level with prior GME training must also be licensed.

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It is the house officer’s responsibility to ensure all licensure requirements are met prior to the appointment date. Failure to do so may result in loss of appointment. All house officers (with the exception of Optometry, Pastoral Care, Health Administration, Student Fellows, Medical Physics, and Community-based Pharmacy) must be ACLS certified prior to arrival. Pediatrics residents may substitute Pediatrics Advanced Life Support (PALS), and Neonatology fellows should have completed the Neonatal Resuscitation Program (NRP). The certification must be American Heart Association (AHA) accredited. OMFS upper year residents must be PALS certified after completing their final year in medical school training. Certification must be maintained throughout the duration of training. GME does not reimburse for the first certification obtained or held when beginning your residency or fellowship program. Subsequent re-certifications are reimbursed through the GME Office. Failure to maintain certification will result in disciplinary action in accordance with the GME Professionalism Policy (see Appendix).

All house officers are expected to complete medical records documentation and electronic order signatures on a regular basis. This policy applies to all sites of training including but not limited to UK (Chandler and Good Samaritan) and the Lexington VA Medical Center. Completion of records should be ensured before going on vacation, scheduled leave, before rotating to another facility outside of Fayette County and before completion of training. House officers should contact Medical Records regarding any incomplete documentation/records within 7 days of anticipated leave or on an off-site rotation that is outside Fayette County. See UK Healthcare Policy A05-110 All house officers are expected to complete GME Institutional or participating site required tasks in a timely manner as assigned. House officers will be appropriately notified of pending tasks. Failure to comply with timely completion of such required tasks may result in disciplinary action per the GME Professionalism Policy (see Appendix).

In order to assure that documentation is completed in a timely manner that is compliant with Joint Commission and other regulating body requirements, the GME office conducts a notification and suspension process. Any house officer suspended for documentation deficiencies has until midnight on the day following suspension to complete the deficiencies. Failure to complete deficiencies by this time will result in additional disciplinary action as outlined in the GME Professionalism Policy (see Appendix). Suspensions for medical record deficiencies are required to be reported on many state licensure applications and medical credentialing requests.

In addition to these general standards, individual programs may have specific academic standards to which house staff are held accountable. House staff must be informed of these specific academic standards at departmental orientation and provided ready access to the relevant documents through the program office. In instances in which the house officer does not attend orientation, it is the program director’s responsibility to assure that the resident is informed of these specific academic requirements.

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VI.B. Remediation and Discipline Policy The primary responsibility for defining the standards of academic performance and personal professional development rests with the program director and faculty of each individual program. In each program, there must be clearly stated basis for evaluation and advancement. Program Directors and supervising faculty must provide and document timely feedback on an ongoing basis for house staff including formative "on-the-spot" and summative feedback. This must include both positive feedback as well as feedback on minor performance or conduct concerns as they occur. Documentation must appropriately reflect the feedback provided.

Most concerns should be managed initially with feedback including informal verbal counseling by the program director and faculty. Failure of the house officer to appropriately remediate after such intervention or concerns that should not be addressed with informal verbal counseling alone must be managed with additional intervention. In those situations, one of the actions listed below (Notice of Concern, Non-Promotion, Probation, Suspension, Dismissal or Non-renewal) is taken, depending on the nature and/or severity of the deficiency, actions, or conduct. In determining which level of intervention is appropriate, the program director should take into account the house officer’s overall performance, including previous evaluations, results of any informal counseling, etc.

Consultation with the DIO and/or Assistant Dean for Graduate Medical Education is required prior to initiation of all actions.

VI.B.1 Preliminary Academic Action/Notice of Concern Program Directors are encouraged to use a Notice of Concern as a preliminary measure to resolve minor instances of poor performance or misconduct but which do not impact the health or safety of patients or others. Actions that may adversely impact on health or safety of patients or others are addressed by Probation, Suspension and/or Immediate Dismissal.

A Notice of Concern may be issued by the Program Director when (1) a house officer’s unsatisfactory performance or conduct is too serious to be dealt with by informal verbal counseling or (2) a house officer’s unsatisfactory performance or conduct continues and does not improve in response to verbal counseling. A Notice of Concern must be in writing, provide an explanation of the unsatisfactory performance or conduct in competency-based language with the expectation of improvement outlined and include a time frame in which the house officer meet these expectations. The time frame should not be greater than three months. Review of the Notice of Concern by the Assistant or Associate Dean is required. The Program Director or designee will then review the Notice of Concern with the house officer which both must sign. A copy is placed in the house officer’s program file. During or at the end of the Notice of Concern Period the house officer will meet with the program director or designee to determine whether the unsatisfactory performance or conduct has been corrected or whether further corrective action will be taken. If the house officer fails to achieve and/or sustain improvement or a repetition of the conduct occurs, then the program director may take additional action including Non- Promotion, Probation, Immediate Dismissal or Non-renewal actions after consulting with the Assistant or Associate Dean.

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This action need not precede other academic actions described later in this document. For the purposes of this policy and for responses to any inquiries, a Notice of Concern does not constitute a disciplinary action. VI.B.2 Formal Disciplinary Actions Formal disciplinary action may be taken for any appropriate reason, including but not limited to any of the following examples:

• Failure to satisfy the academic or clinical requirements or standards of the training program expected for the level of training;

• Any inadequacy or conduct which adversely bears on the individual's performance, such as attitude, conduct, interpersonal or communication skills, or other misconduct;

• Violations of professional responsibility, policies and procedures, state or federal law or any other applicable rules and regulations.

Formal disciplinary action may include, but is not limited to:

• Non-promotion of a House Officer • Probation • Suspension • Non-renewal of appointment • Dismissal/termination

See below for more description

VI.B.2.a). Non-promotion of a House Officer If a house officer has not met the program standards sufficiently in his or her current training level, the program may make a decision not to promote a house officer to the next level of training in lieu of dismissal from the program. An official period of probation may or may not be indicated.

The house officer should be notified of this decision as soon as circumstances reasonably allow, and in most cases four months prior to the end of the contract year. Exceptions to this timeframe would include performance issues that primarily arise within the final four months of the contract year. If a house officer has received a notice of concern or is on probation, and the end of the house officer’s remediation period is within four months of the end of the contract year, the fact that the house officer is remediating will serve as notice that the house officer may not be promoted.

The notice of non-promotion should outline the remediation steps to be accomplished prior to the house officer’s advancement to the next level and provide an estimation of the amount of remediation time anticipated. As determined by the applicable specialty/subspecialty board, the total training time in the program may be lengthened by the duration of remediation. The house officer will be paid at his or her present level until he/she is advanced to the next level. If the house officer does not successfully complete the remediation plan, the process listed below for dismissal will apply.

House staff may appeal being non-promotion using the house officer grievance procedure (AR 5:5;

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Grievance Procedure for House Officers).

VI.B.2.b). Probation If a house officer’s academic or clinical performance, attitude, behavior, or interpersonal or communication skills puts him/her in jeopardy of not successfully completing the requirements of the training program or other deficiencies exist which are not corrected by informal verbal counseling or a preliminary academic action, or are of a serious nature such that informal verbal counseling or a preliminary academic action are not appropriate, the house officer is placed on Probation. Probation should be used instead of a Notice of Concern when the underlying deficiency requires a substantial change in house officer oversight.

Probation may include, but is not limited to, special requirements or alterations in scheduling a house officer’s responsibilities, a reduction or limitation in clinical responsibilities or enhanced supervision of the house officer activities. This temporary modification of the house officer’s participation in or responsibilities within the training program are designed to facilitate the house officer’s accomplishment of the program requirements. The house officer will be informed in writing by the Program Director that he/she is being placed on Probation. Written notification should include an explanation of the deficiencies, performance or conduct in competency-based language giving rise to Probation, remediation requirements (what the house officer must accomplish in order to come off of probation), the anticipated length of probation, method of ongoing evaluation, a faculty advisor/supervisor for the probationary period, and the time period of the Probation. The length and conditions of the Probationary Period must be determined by the Program Director, after consultation with the Assistant or Associate Dean for GME. Probationary periods must be time-limited. All rotations during the probationary period should be within the sponsoring institution. Failure to meet the terms of probation may result in dismissal from the training program or nonrenewal of contract. If a house officer is on probation, and the end of the house officer’s probation period is within four months of the end of the contract year, the fact that the house officer is on probation will serve as notice that the house officer contract may not be renewed or he/she may be dismissed from the program if the probation is not remediated successfully.

House staff may appeal being placed on probation using the house officer grievance procedure (AR 5:5; Grievance Procedure for House Officers). VI.B.2.c). Suspension In urgent circumstances, a house officer may be administratively suspended from all or part of assigned responsibilities by his/her department chairperson, program director, or the Chief Medical Officer (or designee) of the University Hospital or of the affiliated institution or facility for cause, including but not limited to failure to meet general or specific academic standards, failure to provide patient care in a manner consistent with expectations, potential impairment of the house officer, potential misconduct by the house officer or failure to work in a collegial manner with other providers. A house officer may also be suspended pending an investigation of an allegation of any of the above concerns.

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A house officer must be notified verbally and in writing as to the reason for suspension. When a house officer is suspended, the Associate or Assistant Dean of GME should be notified prior to suspension or as soon as possible thereafter. The program shall maintain documentation that the house officer has received written notification and a copy of the notification must be sent to the GME Office. Unless otherwise directed by the program director, a house officer suspended from clinical services may not participate in other program activities. Suspension is generally with pay. Suspensions must be time- limited but can be renewed if appropriate. A suspension may be coupled with or followed by other academic actions or conclude in the house officer being reinstated.

House staff may appeal being placed on suspension using the house officer grievance procedure (AR 5:5; Grievance Procedure for House Officers). VI.B.2.d). Non-Renewal of Appointment While house officers are generally granted a renewal of contract annually until they have achieved board eligibility, program directors may determine that continuation in the program is not warranted because of deficiencies in academic progress or for other reasons. A prior period of probation or suspension is not required. A decision regarding reappointment must be reached by the program director no later than March 1 (unless the house officer is on suspension or probation) of the year of the current appointment (for house officers on a July 1-June 30 contract year; no later than 4 months prior to end of the current appointment if on an off-cycle contract).

The notice of non-renewal of contract must be approved by the Assistant or Associate Dean for GME. The notification will be made in writing to the house officer with a copy to the official GME file. If the primary reason for the non-renewal occurs within the four months prior to the end of the contract, the program must provide the house officer with as much written notice of the intent not to renew as the circumstances will reasonably allow. The house officer may be offered the opportunity to conclude the remainder of the academic year or to resign from the program. For those who continue, at his/her appointed level of training through the end of the contract period full credit for the year may be given to the house officer at the discretion of the Program Director and guidelines of the individual board. If deficiencies in professional competence that may endanger patients arise during continued training under a non-renewal status, the house officer may be terminated or suspended immediately after consultation with the Assistant or Associate Dean for GME. A decision of non-renewal of appointment may be appealed using the house officer grievance procedure (AR 5:5; Grievance Procedure for House Officers).

VI.B.2.e). Dismissal/Termination A house officer may be dismissed from a program because of failure to remediate deficiencies during a probationary period; suspension or revocation of the house officer’s license or permit; conduct constituting criminal activity; gross and serious violation of expected standards of patient care; failure to abide by the Behavioral Standards or the applicable regulations of the University of Kentucky, and or other hospitals and facilities to which the house officer may rotate or other responsibilities as specified by the program; or gross and serious failure to work in a collegial manner with other providers. This decision should involve multiple individuals at the program/departmental level. The program must consult with the Associate or Assistant Dean of GME in dismissal decisions. Dismissal may, depending

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upon the situation, be immediate or follow a period of suspension and/or probation. Insofar as is possible, a house officer should be notified in person and in writing about the dismissal decision. This notification must include the reason for the dismissal decision, the date of the dismissal, and method for appeal. Credit for training may be given in the event of any satisfactory performance prior to dismissal, per the guidelines of the individual board.

House staff may appeal being dismissed using the house officer grievance procedure (AR 5:5; Grievance Procedure for House Officers).

VI.C. Clearance Each house staff officer completing training or leaving must clear both the University and the VA Medical Center (if applicable) before leaving. This clearance includes Medical Records, the Medical Library, the Hospital Cafeteria, and other offices. Additionally, check with your program for any program-specific clearance procedures. All debts incurred with the University during training must be paid prior to completing the GME clearance process. VII. House Staff Well-Being

VII.A. Self-Care and Well-Being Residents and faculty members are at increased risk for burnout and depression. Psychological, emotional, and physical well-being are critical in the development of the competent, caring, and resilient physician. Self-care is an important component of professionalism; it is also a skill that must be learned and nurtured in the context of other aspects of residency training. The institution, in addition to each training programs has the same responsibility to address well-being as they do to evaluate other aspects of resident competence. Programs, in partnership with the institution, must make specific efforts to enhance the meaning that each resident finds in the experience of being a physician, including protecting time with patients, minimizing non-physician obligations, providing administrative support, promoting progressive autonomy and flexibility, and enhancing professional relationships. This responsibility must include paying attention to scheduling, work intensity, and work compression that impacts resident well-being; evaluate workplace safety data and addressing the safety of residents and faculty members; creating policies and programs that encourage optimal resident and faculty member well-being. Residents must be given the opportunity to attend medical, mental health, and dental care appointments, including those scheduled during their working hours. The institution and programs must direct attention to resident and faculty member burnout, depression, and substance abuse. The program, in partnership with the institution, must educate faculty members and residents in identification of the symptoms of burnout, depression, and substance abuse, including means to assist those who experience these conditions. Residents and faculty members must also be educated to recognize those symptoms in themselves and how to seek appropriate care. The program, in partnership with the institution, must encourage residents and faculty members to alert the program director, the GME office, appropriate departmental faculty content, or other programs when they are concerned that another resident, fellow, or faculty member may be displaying signs of burnout,

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depression, substance abuse, suicidal ideation, or potential for violence. VII.B. Coverage of Patient Care There are circumstances in which residents may be unable to attend work, including but not limited to fatigue, illness, and family emergencies. Each program must have policies and procedures in place that ensure coverage of patient care in the event that a resident may be unable to perform their patient care responsibilities. These policies must be implemented without fear of negative consequences for the resident who is unable to provide the clinical work. (Core) VII.C. Counseling and Mental Health Resources Non-emergent Counseling and Mental Health Resources: Lexington Medical Society Physician Wellness Program: call 1-800-350-6438 • Any UK GME House Staff member can access • Free and confidential counseling service not connected to UK or your health insurance • 8 free counseling sessions a year (count based upon calendar year) via The Woodland Group • Resource is available for any support need whether related to depression or anxiety, work related

stressors, relationship concerns or just difficulty coping with the demands of residency or fellowship. Participants are able and encouraged to bring family members, spouses or significant others as relevant to the situation (example: couples counseling is covered through this service)

• Individuals utilizing this service will remain anonymous to GME and the Lexington Medical Society • While appointments are generally available from 8-5pm, early morning or evening appointments may be

arranged. UK Work-Life Counseling: http://www.uky.edu/hr/work-life/counseling/worklife-connections-counseling

• Individual Counseling for life stress, work performance, substance abuse concerns, mental health REFER Program: http://www2.ca.uky.edu/hes/familycenter/refer-program.htm UK Family Center Counseling focused upon personal, couple, or family concerns. REFER is staffed by Marriage and Family Therapist-In-Training, educated with the skills necessary to help work through a variety of personal issues. Contact the UK Family Center at 257-1467 or 257-7755 for additional information. UK Department of Psychiatry Outpatient Clinic Access to confidential consultation is available through the UK Outpatient Clinic during business hours, five days per week. The telephone number is 859-323-6021. Follow prompts for the Outpatient Clinic. Emergent Counseling and Mental Health Resources: The Ridge Behavioral System Under the auspices of the Department of Psychiatry, access to confidential consultation regarding the need for emergency psychiatric services is available to house staff 24 hours per day, seven days a week through the admissions office at The Ridge Behavioral System. The telephone number to call is 859-268-6400. The house officer is to ask for the Assessment Office and identify him/herself as a UK resident/fellow needing immediate evaluation. If admission is required, the caller will be asked to go

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directly to The Ridge, bypassing evaluation in the UK Emergency Department. If utilizing the Ridge is not feasible or in a situation where a resident or faculty member is actively suicidal and cannot be safely transported to the Ridge, emergency psychiatric services are also available via the UK emergency room. VII.D. Impairment Policy Impairment is defined as “the inability to practice medicine with reasonable skill and safety due to physical or mental illness, loss of motor skills or abuse of drugs including alcohol” (American Medical Association). It is professional misconduct to practice medicine while impaired. The University of Kentucky is committed to the provision of support and appropriate referral for house staff whose performance may be impaired due to psychological stress, psychiatric illness or abuse of drugs and/or alcohol. Accordingly, programs must assure that all house staff are aware of these services and informed of the mechanisms through which they may confidentially access them, either to address problems they are experiencing personally, or to intervene when problems are suspected or observed in a peer. The University of Kentucky will take all reasonable steps to protect the confidentiality of the house officer who seeks voluntary treatment or is referred for treatment subject to applicable legal constraints and the provisions of this policy. Services available for voluntary self-referral related to mental health concerns that pose a risk of impairment are listed above under ‘Counseling and Mental Health Resources’.

VII.E. Voluntary Self-Referral for Drug/Alcohol Counseling in the Absence of Performance Issues Services available for voluntary self-referral related to drug/alcohol treatment in the absence of performance issues include:

VII.E.1. Impaired Physicians Program The Impaired Physicians Program (IPP) of the Kentucky Physicians Health Foundation (or equivalent for other specialties) will provide assistance to physicians with mental health or drug/alcohol related illness. It provides evaluation, referral for treatment and ongoing aftercare including regular meetings and compliance monitoring. IPP serves as an advocate for the recovering physician with the Kentucky Board of Medical Licensure and other appropriate agencies. Help for oneself or a peer can be obtained confidentially by calling 502-425-7761.

For house staff who seek treatment or who require further voluntary evaluation and possibly treatment, the program director should notify the Associate Dean for GME who will assist the house officer in contacting the IPP. A house officer who has enrolled in an IPP approved treatment program may be permitted to return to the training program with agreement of the IPP and in accordance with the “Return to Duty Section” of this policy.

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VII.E.2. Required Evaluation for Mental Health or Drug/Alcohol Concerns by Others in the Context of Performance Related Concerns Policy

When a house officer is experiencing performance-related problems or engaging in behavior in which impairment is suspected, the institution shall have the right to require the house officer to undergo further evaluation.

Any instance in which another house officer, faculty member, other hospital employee, patient or patient’s family, or other person suspects that a house officer is impaired during the exercise of his/her professional duties, may be reported. These incidents may include, but are not limited to, perceived problems with judgment, behavior, speech, emotional outbursts, depression, alcohol odor or other perceptions of impairment.

Reports of suspected impairment should go to the house officer’s attending physician or program director. Upon receiving such a report, the attending physician or program director should immediately meet with the house officer to ascertain if there is cause for concern. The attending physician must make the program director aware of the situation. It is recommended that the Assistant or Associate Dean for GME also be advised.

The program director shall make a reasonable effort to determine whether the report is reasonable for suspected impairment. If the program director determines that the report does not indicate suspected impairment, and that there are no performance concerns with respect to the house officer, no further action will be taken. Documentation of this assessment should be recorded by the program director. If the program director determines that there is cause for concern, the Assistant or Associate Dean for GME must be contacted and a course of action shall be determined, which may include but is not limited to further inquiry, suspension, or house officer testing using UK HealthCare Policy # A09-005 Fitness for Duty Evaluations. VII.F. Return to Work If treatment or rehabilitation is recommended by the IPP, and the house officer enrolls in an IPP- approved treatment program, the house officer will be required to waive his/her right to confidentiality to the extent that:

• the program director and Assistant or Associate Dean for GME will be notified as to whether the proposed treatment plan limits the house officer’s ability to work, and if so, will be provided with a description of the limitations,

• the program director and Assistant or Associate Dean for GME will be notified periodically whether the house officer is participating in the treatment plan and whether treatment has been successful; and

• any other information needed to assess the house officer’s continued fitness for the training program.

Whether a house officer will be allowed to return to duty or complete his/her training will be evaluated on a case-by-case basis, taking into consideration the recommendations of the treatment

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program;, the limitations, if any, on the house officer’s ability to practice and expected duration of the limitations; whether reasonable accommodations can be made by the training program; the circumstances that give rise to the initial report of potential impairment (i.e. whether any serious incidents or violations of law occurred); and whether patient and staff safety can be maintained.

VII.G. Refusal to Cooperate If a house officer who requires further treatment as determined by the IPP refuses to enroll or remain enrolled with the IPP, the program director will be obligated to report the house officer to the Kentucky Board of Medical Licensure. In addition, the house officer may be suspended or terminated from the training program. The house officer shall have the right to appeal the suspension and/or termination pursuant to the appeal procedures set forth in AR 5:5, “Grievance Procedure for House Officers.”

VIII. PROGRAM EDUCATIONAL CURRICULUM (See II.B. Program Administration)

VIII.A. Curriculum The program director, in conjunction with the faculty must outline a curriculum that contains the following educational components:

• Overall educational goals for the program, which the program must distribute to house staff and faculty annually; Competency-based goals and objectives covering all applicable competencies for each assignment at each educational level, which the program must distribute to house staff and faculty annually, in either written or electronic form. These should be reviewed by the house officer at the start of each rotation;

• Regularly scheduled didactic sessions; and, • Clear delineation of resident responsibilities for patient care, progressive responsibility for

patient management, and supervision of house staff over the continuum of the program.

The training program must require its house staff to develop the competencies as listed below to the level expected of a new practitioner. Toward this end, programs must define the specific knowledge, skills, and attitudes required and provide educational experiences as needed in order for their house staff to demonstrate the competencies.

PATIENT CARE and PROCEDURAL SKILLS House staff must be able to: provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health; competently perform all medical, diagnostic, and surgical procedures considered essential for the area of practice; and as further specified by the Program Review Committee.

MEDICAL KNOWLEDGE House staff must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care and as further specified by the Program Review Committee.

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PRACTICE-BASED LEARNING AND IMPROVEMENT House staff must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self- evaluation and life-long learning. House staff are expected to develop skills and habits to be able to meet the following goals:

• Identify strengths, deficiencies, and limits in one’s knowledge and expertise; • Set learning and improvement goals; • Identify and perform appropriate learning activities; • Systematically analyze practice using quality improvement methods, and implement changes

with the goal of practice improvement; • Incorporate formative evaluation feedback into daily practice; • Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health

problems; • Use information technology to optimize learning; • Participate in the education of patients, families, students, house staff and other health

professionals; • and [as further specified by the Program Review Committee.]

INTERPERSONAL AND COMMUNICATION SKILLLS House staff must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. House staff are expected to:

• Communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds;

• Communicate effectively with physicians, other health professionals, and health related agencies;

• Work effectively as a member or leader of a health care team or other professional group; • Act in a consultative role to other physicians and health professionals; and, • Maintain comprehensive, timely, and legible medical records, if applicable; • and [as further specified by the Program Review Committee.]

PROFESSIONALISM House staff must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. House staff are expected to demonstrate:

• Compassion, integrity, and respect for others; • Responsiveness to patient needs that supersedes self-interest; • Respect for patient privacy and autonomy; • Accountability to patients, society and the profession; and, • Sensitivity and responsiveness to a diverse patient population, including but not limited to

diversity in gender, age, culture, race, religion, disabilities, and sexual orientation; • and [as further specified by the Program Review Committee.]

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SYSTEMS-BASED PRACTICE House staff must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. House staff are expected to:

• Work effectively in various health care delivery settings and systems relevant to their clinical specialty;

• Coordinate patient care within the health care system relevant to their clinical specialty; • Incorporate considerations of cost awareness and risk benefit analysis in patient and/or

population-based care as appropriate; • Advocate for quality patient care and optimal patient care systems; • Work in inter-professional teams to enhance patient safety and improve patient care quality;

and, • Participate in identifying system errors and implementing potential systems solutions; • and [as further specified by the Program Review Committee.]

VIII.B. House staff Scholarly Activities The program director, in conjunction with the faculty must outline a curriculum and allocate adequate educational resources to advance house staff knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care. All house staff should participate in scholarly activity. The University of Kentucky is committed to providing educational resources to facilitate house staff involvement in scholarly activities.

VIII.C. Other Learners Policy The presence of other learners (including, but not limited to, residents from other specialties, subspecialty fellows, PhD students, medical students and nurse practitioners) in the program must not interfere with the appointed house officers’ education. The program director must report the presence of other learners to the DIO and GMEC upon request and as part of each Annual Program Evaluation.

VIII.D. Experimentation and Innovation Requests for experimentation or innovative projects that may deviate from the institutional, common and/or specialty specific program requirements must be approved in advance by the Review Committee.

Both the sponsoring institution and the program must hold a status of Accreditation or Continued Accreditation. The proposal must include a request for a waiver/variation/suspension of a common, institutional or specialty-specific standard. The request for a waiver/variation/suspension of specialty- specific standard(s) must involve specialty-specific standard(s) overseen by only one RC.

In preparing requests, the program director must follow Procedures for Approving Proposals for Experimentation or Innovative Projects located in the ACGME Manual on Policies and Procedures. This proposal is first submitted to the Compliance Subcommittee for review with a subsequent recommendation to the GMEC for final decision. Approval from the GMEC and signature by the DIO is required prior to submission to the Executive Director of the appropriate ACGME Review Committee. Once a Review Committee approves a project, the sponsoring institution and program are jointly

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responsible for monitoring the quality of education offered to residents for the duration of such a project. IX. EVALUATION The primary responsibility for defining the standards of academic performance and personal professional development rests with the program director and faculty of each individual program. House staff must know and understand the performance criteria on which they will be assessed. The program director must provide the house staff with copies of the assessment tools to be used as part of the evaluation process. The program director and faculty must define the performance standards (i.e., pass/fail mark of a learning experience or ‘how much is enough’ to advance one training level to the next). The goal is that both faculty and house staff share a common understanding of what is expected and how it will be evaluated and that the house staff perceives assessments as a fair and close approximation of actual ability. In each program, there must be clearly stated basis for evaluation and advancement. Program Directors and supervising faculty must provide and document timely feedback on an ongoing basis for house staff including formative "on-the-spot" and summative feedback. This must include both positive feedback as well as feedback on minor performance or conduct concerns as they occur. Documentation must appropriately reflect the feedback provided. End of rotation evaluations of the house staff by the faculty must be completed within two weeks of the last day of contact.

IX. A. House Staff Evaluation/Clinical Competency Committee The program director must appoint a Clinical Competency Committee (CCC) for each program. At a minimum the CCC must be composed of three members of the program faculty. Others eligible for appointment to the committee include faculty from other programs and non-physician members of the health care team who have frequent contact with the house staff. The program must have a policy that describes the responsibilities of the committee. The CCC should: review all resident evaluations semi-annually; prepare and assure the reporting of Milestones evaluations of each resident semi- annually to ACGME; and, advise the program director regarding resident progress, including promotion, remediation, and dismissal. The meeting of the CCC does not substitute for the required documented semiannual evaluation of the house officer by the Program Director.

IX.A.1. Formative Assessment House officer performance must be assessed during each rotation or similar educational assignment in a timely manner. Formative assessments should include both informal ‘on-the-spot’ verbal feedback and written assessments. Examples of assessment methods include: direct observation, global assessment, simulations/models, record/chart review, standardized patient examination, multisource assessment, project assessment, patient survey, in-house written examination, in-training examination, oral exam, objective structured clinical examination, formal oral exam, practice/billing audit, review of case or procedure log, review of patient outcomes, review of drug prescribing, house officer experience narrative and any other applicable assessment method.

Written or electronic formative assessment should be used to provide a mechanism through which programs can document progressive resident performance improvement. Programs should use house

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officer self-assessment as an important component of formative assessment, both to compare with data from other evaluators and also to help the learner develop important lifelong learning skills.

Programs must use the GMEC approved Medical Student Evaluation of the Resident and Resident Evaluation of the Faculty assessment tool for medical student-house staff/faculty-house staff interactions during rotations. Confidentiality of the evaluator must be assured.

The primary purpose of any formative assessment is to capture the process of developing abilities. This allows house staff to recognize learning gaps in knowledge, skills, and behaviors, to guide planning for further learning and to identify the need for remediation.

As part of the formative assessment process the program must:

• Provide objective assessments of competence in patient care, medical knowledge, practice- based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice as applicable to the educational assignment;

• Use multiple evaluators (e.g., faculty, peers, patients, self, medical students and other professional staff); and,

• Document progressive resident performance improvement • Document resident performance semiannually

IX.A.2. Semiannual Evaluation The program director or designee must provide each house officer with a written or electronically documented semiannual evaluation of performance with feedback. The semiannual evaluation must be used to document the current level of house officer performance compared to the performance criteria established for a given post graduate year (PGY). The results of the semiannual evaluation should be used by the programs in decision making for promotion to the next PGY or graduation. Remediation and discipline policies may be applicable.

Each semiannual evaluation must include a review of:

• Competency based formative assessments by faculty, peers, patients, self, medical students or other professional staff

• Procedural data, as applicable • Review of rotation schedule • Didactic attendance • Scholarly activity including research • Individual compliance with duty hours requirements • Performance on in-training examination, as applicable • Professionalism

All documented formative assessments, semiannual evaluations, and any other assessments of resident performance must be confidentially maintained in an individual house officer file by the program and accessible for review by the house officer upon request.

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IX.A.3. End-of-Program Summative Evaluation Policy The program director must provide a final summative evaluation for each house officer upon completion of the program. Completion of the program is applicable to any house officer transferring to another program, graduating at the end of training, or completing a preliminary year of training before entering a specialty program. This evaluation must be reviewed with the house officer, signed by both the Program Director and the house officer, and kept as a permanent record with a copy maintained in the both the program file and the GME resident file. The resident is provided the original, signed copy for their records

This summative evaluation must:

• Document the resident’s performance during the final period of education including an evaluation of competence in the following areas:

1. Patient Care including procedural data, as applicable 2. Medical Knowledge 3. Practice-Based Learning and Improvement 4. Interpersonal and Communication Skills 5. Professionalism 6. Systems-Based Practice;

• Document any formal disciplinary actions that occurred during training; • Provide a verification statement by documenting in a written format that the resident has

“demonstrated sufficient competence to enter practice without direct supervision”. House staff may not graduate, even if the specified time for residency education has expired, if the program director does not feel comfortable signing such a statement; and,

• Any additional documentation as further specified by the Review Committee or applicable certifying Board.

Programs must use the GMEC approved standard templates for Final Summative Evaluations.

IX.B. Faculty Evaluation Policy Regular evaluation of faculty is critical to maintaining and improving the quality and effectiveness of a program. At least annually, the program must evaluate faculty performance as it relates to the educational program and provide feedback. Faculty should be evaluated on their clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism, and scholarly activities. This process must include review of those evaluations completed by house staff. Other quality indicators should also be reviewed.

House staff are to complete electronic confidential evaluations of the faculty after each rotation, educational assignment or no less often than quarterly. House staff should evaluate only those areas on which they have direct knowledge and information on which to judge quality. All house staff evaluations of the faculty are distributed and monitored for compliance by the program. A program that chooses to do additional faculty evaluations by the house staff must ensure a process that maintains house staff confidentiality.

House staff evaluation of the faculty results are provided to program leadership on an annual basis in a

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summative format only after meeting a minimal required number of assessments to ensure confidentiality for the house staff. Faculty receive aggregated numerical ratings for each assessment question along with a comparison of the faculty members’ ratings relative to peers in the same department and peers in the College of Medicine. Narrative comments from which all identifying information has been removed are provided.

IX.C. Program Evaluation and Improvement Policy The program must document formal, systematic evaluation of the educational curriculum at least annually. All programs of training duration greater than one year must precede the annual program evaluation with a confidential written or electronic evaluation of the program by both the house staff and the faculty. The program must use the results of residents’ and faculty members’ assessments of the program together with other program evaluation results to improve the program. The annual program evaluation must be completed by a Program Evaluation Committee (PEC) that is appointed by the Program Director. The Program Evaluation Committee: must be composed of at least two program faculty members and should include at least one resident; must have a written description of its responsibilities; and, should participate actively in:

• planning, developing, implementing, and evaluating educational activities of the program; • reviewing and making recommendations for revision of competency-based curriculum goals

and objectives; • addressing areas of non-compliance with ACGME standards; and, • reviewing the program annually using evaluations of faculty, residents, and others, as specified

below.

The program, through the PEC, must document formal, systematic evaluation of the curriculum at least annually, and is responsible for rendering a written and Annual Program Evaluation (APE). The program must monitor and track each of the following areas: resident performance; faculty development; graduate performance, including performance of program graduates on the certification examination; program quality; and, progress on the previous year’s action plan(s). Examples of house staff performance indicators include the results of aggregated formative assessments, national comparison data such as in-training exams and scholarly activity including presentations/publications. Faculty development activities include not only CME-type activities directed toward acquisition of clinical knowledge and skills, but also activities directed toward developing teaching abilities, professionalism, and abilities for incorporating the competencies into practice and teaching. Graduate performance indicators must include the results of performance on board certification examinations. Annual surveys of graduates assessing current professional activities and perceptions on how well prepared graduates are as a result of the program should be completed.

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Additional program quality indicators must be reviewed such as assessments of rotations or specific assignments, house staff selection process, graduates’ practice choices, the didactic curriculum, assessment system used for house staff, results of house staff evaluation of faculty, results of the most recent annual ACGME resident/fellow survey, duty hours monitoring, and patient outcomes linked to house staff performance. The PEC must prepare a written plan of action to document initiatives to improve performance in one or more of the areas listed above, as well as delineate how they will be measured and monitored. The action plan should be reviewed and approved by the teaching faculty and documented in meeting minutes. A copy of the annual program evaluation must be forwarded to the GME office for DIO review. The program director must indicate to the DIO any deficiencies that require additional resources for resolution. The Program Director must document the presence of other learners and any negative impact of house staff training. Programs are encouraged to use the annual program evaluation template provided by the GME office.

X. THE LEARNING AND WORKING ENVIRONMENT Professionalism, Personal Responsibility, and Patient Safety: The University of Kentucky and its programs are committed to and responsible for providing house staff with a blend of supervised patient care responsibilities, clinical teaching, and didactic educational events, which must be carefully planned and balanced with concerns for patient safety and house staff well-being. House staff should not be routinely involved in the provision of patient support services such as peripheral intravenous access placement, phlebotomy, and laboratory and transporter services. Laboratory, pathology, and radiology services must be in place to support timely and quality patient care. A medical records system that documents the course of each patient’s illness and care must be available at all times and must be adequate to support quality patient care, residents’ education, quality assurance activities, and provide a resource for scholarly activity.

These types of support services should not be confused with the service provided by the house staff as part of the patient-physician relationship. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on house staff to fulfill service obligations in the absence of learning. Every patient encounter is an opportunity for the house staff to learn. House staff participating in the care of patients on a busy patient care team should not be misinterpreted as service as long as appropriate teaching and feedback accompany it from the upper level resident/fellow and/or faculty. Didactic and clinical education must have priority in the allotment of house staff time and energies. Clinical and educational assignments must recognize that faculty and house staff collectively have responsibility for the safety and welfare of patients.

The program director along with the University of Kentucky is committed to ensuring a culture of professionalism that supports patient safety and personal responsibility. House staff and faculty members must demonstrate an understanding and acceptance of their personal role in the following:

• assurance of the safety and welfare of patients entrusted to their care; • provision of patient- and family-centered care; • assurance of their fitness for duty;

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• management of their time before, during, and after clinical assignments; • recognition of impairment, including illness and fatigue, in themselves and in their peers; • attention to lifelong learning; • the monitoring of their patient care performance improvement indicators; • honest and accurate reporting of duty hours, patient outcomes, and clinical experience data;

and • for additional information see House Staff Responsibilities as outlined above

All house staff and faculty members must demonstrate responsiveness to patient needs that supersedes self-interest including recognizing that under certain circumstances, the best interests of the patient may be served by transitioning that patient’s care to another qualified and rested provider. The program director must ensure that house staff are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs.

X.A. Transitions of Care:

Programs must design clinical assignments to minimize the number of transitions in patient care. Programs in conjunction with the University of Kentucky must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety. Programs must ensure that residents are competent in communicating with team members in the hand-over process. The University of Kentucky in conjunction with its participating clinical training sites will ensure the availability of schedules that inform all members of the health care team of attending physicians and house staff currently responsible for each patient’s care through available mechanisms.

X.B. Alertness Management/Fatigue Mitigation: Faculty and house staff must receive education in alertness, fatigue mitigation, how to recognize signs of fatigue and sleep deprivation. This education occurs through GME Orientation for all house staff, use of available on-line modules, departmental conferences/grand rounds, or any other appropriate educational tool.

All faculty members and house staff must be encouraged to adopt fatigue mitigation processes such as naps, to manage the potential negative effects of fatigue on patient care and learning. In the event a house officer may be unable to perform his/her patient care duties due to fatigue, illness, or similar issues the program must have a clearly defined back-up plan in place to ensure continuity of patient care.

A House officer who may be too fatigued to safely return home has the option of using the already available nap rooms to sleep or safe transportation via taxi (through https://cabvoucher.mc.uky.edu) to home with a return trip back within 24 hours.

X.C. Supervision of House Staff Policy All patient care must be supervised by an identifiable, appropriately-credentialed and privileged attending physician who has ultimate responsibility for patient care. The program director should ensure this information is available to house staff, other faculty, and hospital administration as appropriate. House staff and faculty should inform patients of their respective roles in each patient’s

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care. At all times, the program director must ensure and document an appropriate level of supervision in place for all house staff caring for patients.

House staff must be provided with rapid, reliable systems for communicating with supervising physician while at the same time experiencing graduated responsibility, assuming greater and greater levels of responsibility for aspects of the patient’s care as their competencies increase and are documented. Supervision may be provided by faculty or a more advanced resident or fellow and exercised through a variety of methods including direct and indirect supervision. The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each house officer must be assigned by the program director and faculty members based on program specific criteria. Each house officer must know the limits of his/her scope of authority, and the circumstances under which he/she is permitted to act with conditional independence. PGY-1 house staff should be supervised either directly or indirectly with direct supervision immediately available. Programs must set guidelines for circumstances and events in which house staff must communicate with appropriate supervising physician or faculty members. Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each house officer and delegate to him/her the appropriate level of patient care authority and responsibility.

Each accredited program must establish a written program-specific supervision policy consistent with this institutional/training site policy and the respective ACGME Common, specialty/subspecialty-specific, or other accrediting body program requirements. This policy must be reviewed annually with the house staff and core faculty and made readily available on MedHub.

X.D. Clinical Responsibilities: The clinical responsibilities for each resident must be based on PGY-level, patient safety, resident education, severity and complexity of patient illness/condition and available support services. Optimal clinical workload may be further specified by each program based upon ACGME Specialty Program Requirements or specialty accrediting body.

X.E. Teamwork: Programs must provide opportunities for house staff to care for patients in an environment that maximizes effective communication. This must include the opportunity to work as a member of effective inter-professional teams that are appropriate to the delivery of care in the specialty as defined by each ACGME specialty Program Requirements or specialty accrediting body.

X.F. Clinical and Educational Experience Guidelines Clinical and educational experiences are defined as all clinical and academic activities related to the training program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Clinical and educational experiences do not include reading and preparation time spent away from the training site. All house staff must document hours of participation clinical and educational experiences in the University of Kentucky residency management system (MedHub) at not less than a rolling two-week interval.

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Note: Individual ACGME Review Committees or specialty accrediting bodies may have more specific requirements.

X.F.1. Maximum Hours of Work per Week: Clinical and educational work hours must be limited to no more than 80 hours per week, averaged over a four-week period, inclusive of all in- house clinical and educational activities, clinical work done from home, and all moonlighting.

X.F.2. Mandatory Time Free of Clinical Work and Education: Training programs must design an effective program structure that is configured to provide residents with educational opportunities, as well as reasonable opportunities for rest and personal well-being. House staff must be provided with a minimum of 1 day in 7 free from all educational and clinical responsibilities, inclusive of both in-house and at-home responsibilities. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities. For purposes of counting, all house staff must have four days off within the first 28 days of any rotation regardless of the day of the month on which the rotation starts. For rotations that extend beyond 28 days, additional days off must be provided using the following format: one day off for every additional seven days worked, two days off for every additional 14 days worked and three days off for every additional 21 days worked, etc. Additional days off are not required for partial weeks worked. The counting process starts over every time a house officer changes rotations. X.F.3. Maximum Length of Clinical and Educational Assignments: Clinical and educational work periods for residents must not exceed 24 hours of continuous scheduled clinical assignments. Programs must encourage house staff to use alertness management strategies in the context of patient care responsibilities. Up to four hours of additional time may be used for activities related to patient safety, such as providing effective transitions of care, and/or resident education. House staff must not be assigned additional patient care responsibilities after 24 hours of continuous clinical and/or educational assignments including but not limited to involvement in continuity clinic, new patient evaluations. Clinical and Educational Work Hour Exceptions In rare circumstances and only after handing off all other responsibilities house staff, on their own initiative, may elect to remain or return to the clinical site in the following circumstances: to continue to provide care for a severely ill or unstable patient, to provide humanistic attention to the needs of a patient or family, or to attend unique educational events. These additional hours of care or educational must be counted towards the 80-hour weekly limit. The program director must track both individual house officer and program-wide episodes of extensions of duty. The occurrence of such extensions of duty should be rare.

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X.F.4. Minimum Time Off between Scheduled Clinical and Educational Assignments: Adequate time for rest and personal activities must be provided. House Staff should have eight hours off between scheduled clinical work and education periods. While there may be circumstances when residents choose to stay to care for their patients or return to the hospital with fewer than eight hours free of clinical experience and education. This must occur within the context of the 80-hour and the one-day-off-in-seven requirements. Residents must have at least 14 hours free of clinical work and education after 24 hours of in-house call. X.F.5. Maximum Frequency of In-House Night Float: Night float must occur within the context of the 80-hour and one-day-off-in-seven requirements. The maximum number of consecutive weeks of night float and maximum number of months of night float per year may be further specified by the applicable RC.

X.F.6. Maximum In-House On-Call Frequency: In-house call must occur no more frequently than every third night, averaged over a four-week period.

X.F.7. At-Home Call: At-home call is defined as responsibility for patient care taken from outside the assigned institution. The frequency of at-home call is not subject to the every third night limitation. House staff taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, when averaged over four weeks.

House staff are permitted to return to the hospital while on at-home call to provide direct care for new or established patients. When house staff are called into the hospital from home, the hours they spend in-house providing patient care must be counted toward the 80-hour maximum weekly limit. The program director and the faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.

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X.F.8. Clinical and Educational Work When Travelling When travel is required due to attending approved educational or clinical conferences, house staff are expected to count this time towards their total work hours. Time spent in actual travel should not be included, instead house staff should log time related to active sessions or trainings.

X.G. Moonlighting Policy Professional and patient care activities that are external to the educational program are called moonlighting. Moonlighting activities, whether internal or external, may be inconsistent with sufficient time for rest and restoration to promote the house officer’s educational experience and safe patient care.

PGY1 medical house staff are not allowed to participate in moonlighting activities. No house officer is required to engage in moonlighting. Each program may determine if moonlighting activities will be allowed.

Because house staff education is a full-time endeavor that only full-time trainees can engage in, the program director must monitor moonlighting hours to ensure that moonlighting does not interfere with the ability of the house officer to achieve the goals and objectives of the educational program.

Each house officer must obtain a prospective, written statement of permission from his/her program director prior to engaging in any moonlighting activities. The written permission form and record of hours worked must become part of the house officer’s file and reviewed appropriately by the program director.

Hours devoted to internal and external moonlighting must be added to training program work hours a n d c o u n t e d t o w a r d s t h e 8 0 h o u r m a x i m u m w e e k l y l i m i t . At no time should a house officer exceed work hour maximums through a combination of training program plus moonlighting activities.

The program director is responsible for monitoring the effect of moonlighting activities upon performance and withdrawing permission to moonlight if necessary.

For further information please refer to the University of Kentucky Moonlighting Policy (see Appendix).

X.H. Program Oversight for House Staff Work Hours Policy Each program must have written policies and procedures regarding house staff supervision and duty hours to ensure compliance with the ACGME institutional, common and specialty/subspecialty program requirements. These policies must be distributed to the house staff and faculty. Monitoring of clinical and educational work assignments and work hours by the program is required with frequency sufficient to ensure appropriate compliance. Faculty and house staff must be educated to recognize the signs of fatigue and to apply proactive and operational counter measures. The program director and faculty must monitor house staff for the effects of sleep loss and fatigue and respond in instances when fatigue may be detrimental to

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resident performance and wellbeing. Back-up support systems must be provided when patient care responsibilities are unusually difficult or prolonged or if unexpected circumstances create house staff fatigue sufficient to jeopardize patient care.

X.H.1. Reporting Work Hours Violations House staff are encouraged to first speak with their chief resident/fellow and/or program director and/or chairperson. Should the house officer feel that he/she has exhausted that route or does not feel comfortable in approaching one of those individual, then he/she should contact the Associate Dean for GME directly or use the Residency Management Software (MedHub) Messaging function to anonymously submit a message to the DIO/GME Director.

X.I. Institutional Oversight of Work Hours Policy Institutional oversight of duty hours is accomplished by multiple mechanisms.

Each program must have written policies and procedures regarding house staff supervision and clinical and educational assignments to ensure compliance with this institutional policy as well as the ACGME institutional, common and specialty/subspecialty program requirements. These policies must be distributed to the house staff and faculty. Monitoring of work hours by the program is required with frequency sufficient to ensure appropriate compliance, therefore Program Directors should review trainee work hours monthly and must review quarterly and document issues via the MedHub PD Work Hour Review module. All house staff are required to continuously log duty hours using MedHub.

As part of each annual program evaluation, the program must assess work hours compliance by review of the program work hours policy, review of logged hours on MedHub, review of the ACGME Resident/Fellow Survey and discussion with house staff and faculty. Compliance with work hours requirements should be recorded in the annual program evaluation report. Oversight for any areas of concern is processed to the GMEC for discussion.

Annually the GME Office must conduct an internal audit of all house staff work hours logged for compliance. Works Hours Reports will be run from MedHub to review compliance indicators. The report(s) will include: • Program Name • Percent House staff completing logs • Average hours per week worked • Number of violations for more than 80 hours per week on average was worked • Maximum number of continuous hours on duty per house officer • Number of violations where 24+4 hour(s) continuous duty was exceeded • Average number of hours off between duty shifts • Average number of days off

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This report summarizes the totals in each of the categories listed above for each program. It is used to evaluate the program's overall compliance and monitor overall institutional compliance.

Programs out of compliance must evaluate their data. If compliance cannot be obtained easily by alteration of trainee schedules, the program director and department chair are asked to meet with the Assistant or Associate Dean for Graduate Medical Education to develop a plan to facilitate compliance.

XI INSTITUTIONAL OVERSIGHT XI.A. Graduate Medical Education Committee Functions and Responsibilities The Sponsoring Institution monitors that each program provides effective educational experiences for house staff that lead to measurable achievement of educational outcomes in the required competencies through the reporting duties of the DIO and the activities of the Graduate Medical Education Committee (GMEC). The GMEC is the entity charged with the oversight of all residency and fellowship programs at the University of Kentucky.

GMEC functions and responsibilities include oversight of:

XI.A.1. the accreditation status of the Sponsoring Institution and all its accredited programs;

XI.A.2. the quality of the GME learning and working environment within the Sponsoring Institution, its accredited programs, and its participating sites;

XI.A.3. the quality of educational experiences in each accredited program that lead to measurable achievement of educational outcomes as identified in the ACGME Common and specialty/subspecialty-specific Program Requirements or other accrediting requirements;

XI.A.4. the ACGME-accredited programs’ annual evaluation and improvement activities; XI.A.5. all processes related to reductions and closures of individual accredited

programs, major participating sites, and the Sponsoring Institution; and, XI.A.6. all phases of educational experiments and innovations that may deviate from

Institutional, Common, and specialty/subspecialty-specific program requirements, including the approval prior to submission to the ACGME and/or respective Review Committee, adherence to Procedures for “Approving Proposals for Experimentation or Innovative Projects” in ACGME Policies and Procedures, and monitoring quality of education provided to residents for the duration of such a project.

GMEC functions and responsibilities include review and approval of:

XI.A.7. institutional GME policies and procedures; XI.A.8. annual recommendations to the Sponsoring Institution’s administration

regarding house staff stipends and benefits; XI.A.9. applications for accreditation of new programs; XI.A.10. requests for permanent changes in house staff complement; XI.A.11. major changes in accredited programs’ structure or duration of education; XI.A.12. additions and deletions of accredited programs’ participating sites;

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XI.A.13. appointment of new program directors; XI.A.14. progress reports requested by an ACGME Review Committee or other

accrediting body; XI.A.15. responses to Clinical Learning Environment Review (CLER) reports; XI.A.16. requests for exceptions to duty hour requirements; XI.A.17. voluntary withdrawal of program accreditation; XI.A.18. requests for appeal of an adverse action by an ACGME Review Committee or

other accrediting body; XI.A.19. and, appeal presentations to any accrediting body.

GMEC functions and responsibilities are accomplished through a variety of mechanisms including: XI.A.20. review of all sponsoring institution and program accreditation letters

of notification and monitoring action plans for correction of areas of noncompliance;

XI.A.21. review of all sponsoring institution and program ACGME annual faculty and house staff surveys;

XI.A.22. development, implementation, and oversight of compliance with written policies and procedures regarding house staff learning and working environment including duty hours, transitions of care, fatigue management, supervision;

XI.A.23. development, implementation, and oversight of compliance with written policies and procedures regarding quality of educational experiences in each accredited program;

XI.A.24. development, implementation, and oversight of compliance with written policies and procedures regarding funding for house staff positions;

XI.A.25. development, implementation, and oversight of compliance with written policies and procedures regarding house staff selection, evaluation, promotion, transfer, discipline, and/or dismissal.

The GMEC demonstrates effective oversight of the Sponsoring Institution’s accreditation through the Annual Institutional Review (AIR). Institutional performance indicators identified for the AIR include:

XI.A.26. results of the most recent institutional self-study visit; XI.A.27. results of ACGME surveys of residents/fellows and core faculty; XI.A.28. notification of accredited programs’ accreditation statuses including

ACGME self-study visits; and, XI.A.29. other institutional and program quality data.

The AIR includes a monitoring procedures for action plans resulting from the review. The GMEC demonstrates effective oversight of underperforming programs through a Special Review process. The Special Review process includes a protocol that:

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XI.A.30. establishes criteria for identifying underperformance; and, XI.A.31. results in a report that describes the quality improvement goals, the

corrective actions, and the process for GMEC monitoring of outcomes. (see Appendix).

The GMEC has numerous responsibilities leading to the assurance that individual programs operate in a manner consistent with accrediting institutional requirements, program requirements, and sponsoring institution policy and procedures. In doing this, it recommends policies to govern GME for adoption by the Medical Staff Executive Committee (MSEC) and, through mechanisms of continuous monitoring, assures that these policies, once adopted, are enforced. Communication between leadership of the organized medical staff and the GMEC is accomplished by committee representation of the DIO or designee. The DIO, who also serves as the Chair of the GMEC, presents the presents the Annual Institutional Review (AIR) report to the organized medical staffs, represented by the Medical Staff Operating Subcommittee of both UK Chandler Hospital and UK Good Samaritan Hospital and the UK Healthcare Committee. The AIR is also provided to the organized medical staffs and governing bodies of major participating sites by written document. The AIR reviews the activities of the GMEC during the past year with attention to, at a minimum, house staff supervision, house staff responsibilities, house staff evaluation, compliance with duty-hour standards, house staff participation in patient safety and quality of care education and the accreditation status of the institution and all accredited programs.

XI.B. Graduate Medical Education Membership Membership in the GMEC includes: each Residency Program Director as a voting ex officio member, nominated Fellowship Program Directors, members of the peer-selected executive committee of the House Staff Council, and a quality improvement/safety officer or his or her designee.

Graduate Medical Education Committee Policy provides additional detail on the membership, voting responsibilities, and procedures related to the GMEC (see Appendix).

There are three standing subcommittees of the GMEC that facilitate its responsibilities:

XI.C. Compliance Subcommittee Membership of the Compliance Subcommittee consists of faculty members who serve on the GMEC, other faculty members, house staff and representatives of the University Hospital and VAMC. Interest in membership is solicited and appointments made from among volunteers by the DIO who serves on the Subcommittee ex-officio. The Subcommittee chairperson is appointed by the DIO. The Subcommittee is staffed by the GME Office.

The Subcommittee continuously monitors, on behalf of the GMEC, GME program compliance with Institutional, Common, and specialty/subspecialty-specific Program Requirements of the Accreditation Council for Graduate Medical Education or other accrediting body. In accomplishing this mission, the Subcommittee pursues all of the following strategies and others

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it deems appropriate: XI.C.1. Reviews program complement change requests XI.C.2. Reviews new program requests XI.C.3. Reviews Annual Program Evaluations of programs and monitor action plans XI.C.4. Reviews Special reviews of programs and monitor action plans for correction XI.C.5. Reviews Self-Study reviews of programs and monitor action plans for

correction XI.C.6. Reviews reports of RC site visits and monitor action plans for correction XI.C.7. Reviews results of ACGME Resident/Fellow Surveys XI.C.8. Reviews Institutional site visit and monitor action plans for correction XI.C.9. Reviews institutional data collected by the GME Office XI.C.10. Reviews GMEC policies XI.C.11. Reviews appointments of new program directors

As part of its program oversight function, the Subcommittee reviews all program communications to the various RCs before they are conveyed. Specifically, this requires that all correspondence to and from the ACGME and its RCs go through the GME office to be shared with the Subcommittee. All ACGME site visit letters go to the Compliance Subcommittee, and program responses to such letters are to be routed to the GME Office, preferably via e-mail. They are then forwarded to the Subcommittee members for review before conveyance to the ACGME. Program directors must therefore assure sufficient time to allow Subcommittee review and action. The final correspondence sent to the ACGME by the program director must be copied to the GME office for the file. It is understood that these initial responses may have a very short turnaround time. Such reviews will thus be expedited and facilitated with electronic communication to the extent possible. A more complete response that outlines steps to be taken to correct any deficiencies/issues noted by the ACGME must be sent to the Subcommittee and should be prepared within three months of receipt of the initial letter (unless otherwise requested by the Subcommittee). The Subcommittee reviews the response, and will either endorse it and send it forward to the GMEC, or return it to the program director to address questions/concerns raised by the Subcommittee. The program director may ask that the Subcommittee send it forward for GMEC consideration without Subcommittee endorsement if he/she doesn't agree with the comments of the Subcommittee. The Subcommittee may ask for progress reports on action plans and report them to the GMEC. Work products of the Subcommittee include recommendations to the GMEC for improvement in GME program compliance and/or in compliance monitoring methods. The GMEC vests authority in the Compliance Subcommittee for time sensitive responses. XI.D. Educational Development Subcommittee

Membership of the Educational Development Subcommittee consists of faculty members who serve on the GMEC, other faculty members as nominated by GMEC members, program

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educational specialists and/or program coordinators and house staff. Membership commitments will be for the entirety of an academic year, and members must commit to attending 70% of meetings over the course of an academic year. Membership will be re-evaluated on an annual basis via review of attendance trends for current members and solicitation for volunteers via GMEC. Membership appointments are made by the DIO who serves on the Subcommittee ex-officio. The Subcommittee chairperson is appointed by the DIO with meetings staffed by a GME Office member. The Subcommittee functions as the GMEC mechanism for development and assessment of educational programs offered at the institutional level relevant to content areas listed by the ACGME as common to all programs or impacting training of the majority of house staff. The subcommittee defines and develops curricula and training encompassing but not limited to the following: development and education for program directors, associate program directors, program administrative staff, faculty and house staff. When in process of developing a new educational program or approach, the subcommittee solicits input and participation widely involving content experts from disciplines not represented on the committee and requesting feedback from GMEC members. Methods or venues chosen for delivery of training and/or curriculum vary in scope, but in general are designed to be relevant across training programs.

The subcommittee conducts meetings via majority agreement regarding agenda items and decisions regarding subcommittee action. The sub-committee is designed to meet monthly but at a minimum must meet no less than every other month.

XI.E. Program Review Subcommittee The purpose of the Program Review Subcommittee is to provide educational oversight and peer review to assist programs with preparation for the ACGME Self-Study. Membership of the Program Review Subcommittee consists of both of GMEC members and non-members including house staff and faculty representatives. Subcommittee members are selected annually through self or peer nomination and review and approval of membership by GMEC. The subcommittee meets at least four times during each academic year and may further subdivide into workgroups to accommodate the volume of programs due for review. To facilitate information sharing relevant to GMEC Compliance Subcommittee oversight duties, the Program Review Subcommittee must have at least 1 member of Compliance Subcommittee present at all meetings. Subcommittee members are available to assist the GMEC with Special Reviews of programs on an ad hoc basis. Additionally, the subcommittee will facilitate review of non-ACGME accredited programs “APE equivalent” documentation. If program review reveals concerns regarding underperformance that could lead to substantial accreditation issues regarding the program’s educational infrastructure or general program operations, the subcommittee will submit a request for a Special Review to the Compliance Subcommittee. The Program Review Subcommittee will review each ACGME accredited training program on a 3 to 4 year rolling schedule. Specific ACGME accreditation timelines and accreditation status will prompt review of a program ahead of the 3 to 4 year cycle.

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These triggers for review include the following: • Any ACGME accreditation status other than Continued Accreditation

• New or continuing program citations on the program’s most recent ACGME annual accreditation letter of notification (LON)

• New or continuing Areas for Improvement on the most recent ACGME annual accreditation LON

• Program undergoes a special review within the past 2 academic years

• Program undergoes a ACGME site visit for non-compliance within the past 2 academic years

• Program ACGME resident survey scores meet threshold for mandatory report to Compliance Subcommittee

Programs without the above triggers for early review will be scheduled for review at least 1 year prior to the anticipated start date of their next ACGME Self-Study. Prior to review of a program, the Program Director for the residency or fellowship program scheduled for review by the subcommittee will receive advance notification from the GME office. The subcommittee schedule will also be disseminated via GMEC at the beginning of each academic year and available on MedHub. The Subcommittee will utilize the following to facilitate program review and guide feedback to programs: • UK GME APE Guide

• ACGME templates for collating and summarizing an APE/APE action plans: http://www.acgme.org/What-We-Do/Accreditation/Self-Study

• Program’s APE and APE action plans for immediate past and prior past academic years

The subcommittee may also request to review the following supplemental data if not included in the program’s APE/action plan or if relevant questions arise during the review process. This information will be provided by the program or the GMEC office to the subcommittee reviewer(s): • Most recent ACGME accreditation status letter

• Board pass data relevant to specialty/ACGME requirements

• Elements of the programs’ last ACGME Annual Data System (ADS) update

• ACGME correspondence within the period of time since the program’s APE or Self-Study

• Program’s most recent house staff and faculty ACGME surveys

• Duty hours trends across program activities

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• ACGME case logs as applicable by specialty

The Subcommittee will utilize the UK GME APE Guide and ACGME Self-Study preparation resources (http://www.acgme.org/What-We-Do/Accreditation/Self-Study) as a rubric to guide review and feedback. The SMART algorithm (Specific Measurable Achievable Realistic Time-bound) will be used to assess APE Action Plans. The Subcommittee will provide written feedback to programs within 1 month after program review is conducted. The GME office will maintain records of subcommittee meetings, minutes and feedback to programs as part of continuous oversight of program improvement processes. Subcommittee minutes will be shared with GMEC at least quarterly. XI.F. House Staff Complement Increase/Funding Requests Request for complement increases and/or funding changes for residents must be anticipated a full year before they are to be effected to allow time for submission to the RC of the ACGME (or equivalent for non-physician specialties/programs) regarding approved positions and changes in the NRMP quota (as applicable). Because the matching program for fellows occurs at various times during the year, requests for complement increases and/or funding changes for fellows must be anticipated a full two years before they are to be effected. All requests for increase in house staff complement and subsequent funding must be approved by both the University of Kentucky Enterprise and the RC of the ACGME (or equivalent for non-physician specialties/programs) before implementation. The Resident/Fellow Complement Increase/Funding Request Policy provides additional information (see Appendix). XI.G. New House Staff Training Program Request Request for new residency training programs must be anticipated more than a full year before they are to be started to allow time for an Enterprise funding decision, submission to the RC of the ACGME (or equivalent for non-physician specialties/programs) all necessary documentation needed for program approval and registration for the NRMP as applicable. Because the matching program for fellows occurs at various times during the year, requests for new fellowship programs must be anticipated often a full two years or more before they are to be effected. All training programs in GME must seek accreditation from the ACGME (or equivalent accreditation body for non-physician specialties/programs) if such accreditation is available. A training program that has chosen not to seek an available accreditation will not be allowed to participate in University of Kentucky GME. All requests for new residency or fellowship training programs must be approved by both the University of Kentucky Enterprise and the RC of the ACGME (or equivalent accreditation body for non-physician specialties/programs) before implementation. Contact with the Associate or Assistant Dean of GME for guidance is required 12-18 months prior to the anticipated start date for residency requests and 18-24 months prior for fellowships.

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The program directors must prepare a written justification for the new training program. The New Resident/Fellow Training Program Request Policy provides additional information (see Appendix). XI.H. Non-ACGME Accredited Training Programs Since 1998, the GMEC has had in place a process whereby non-ACGME (or equivalent) training programs can be reviewed and approved for a training certificate upon completion. That process is for the individual who is responsible for the non-accredited program to submit to the GMEC a proposal outlining the training program that includes its duration, clinical duties, competency-based learning objectives, supervisory lines of authority, qualifications of trainee, and evaluation methodology. It must also address how house staff in an accredited training program will be impacted by trainees in the proposed program, and letters of support from all impacting training programs and institutions (if any of training will occur outside UK) must be included with proposal. If approved by the GMEC, the individual appointed into the training program will be issued a certificate upon completion of the training.

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Policy Modification All policies may be modified or amended at any time. Updated versions of this manual will be posted periodically on the University of Kentucky GME website and program directors notified when an update has been posted. Updated policies become effective upon posting.

Approved by the GMEC: 12-15-2010

Revisions approved by GMEC: 08-24-2011 09-24-2014 05-27-2015 09-28-2016

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APPENDIX Code of Conduct Addendum Education Resources for Critical Care Programs Policy Education Resources for Pain Medicine Program Policy Extreme Event Policy for Emergent Situation or Disaster Graduate Medical Education Committee Policy Graduate Medical Education Professionalism Policy Graduate Medical Education Committee Special Review Policy Grievance Procedure for House Officers House Staff Council Policy International Rotations Policy Moonlighting Policy

Moonlighting Request Form Moonlighting Approval Form

New Resident/Fellow Training Program Request Policy Program Director Protected Time and Support Policy Resident/Fellow Complement Increase/Funding Request Policy Responsibilities of the Residency and Fellowship Program Director Statement of Commitment to Graduate Medical Education

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